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HANDBOOK 

OF 

DISEASES OF THE RECTUM 




PLATE I. 

Cancer of the rectum complicating prolapsing hemorrhoids. Illus- 
trating the importance of proctoscopic examination in all cases of ap- 
parently minor anorectal conditions. 

C. Cancer. 

N. Normal rectal mucous membrane. 

H. HeiTiorrhoids. 



HANDBOOK OF DISEASES 



OF THE 



RECTUM 



BY 

LOUIS J. HIRSCHMAN, M. D. 

FELLOW AMERICAN PROCTOLOGIC SOCIETY; LECTURER ON 
RECTAL SURGERY AND CLINICAL PROFESSOR OP PROC- 
TOLOGY, DETROIT COLLEGE OF MEDICINE; AT- 
TENDING PROCTOLOGIST, HARPER HOSPITAL, 
PROVIDENCE HOSPITAL, AND U. J. C. 
CLINIC, ETC., DETROIT, U. S. A. 



WITH ONE HUNDRED AND SEVENTY-TWO 

ILLUSTRATIONS, MOSTLY ORIGINAL, 

INCLUDING FOUR COLORED PLATES 



SECOND EDITION 
REVISED AND REWRITTEN 



ST. LOUIS 

C. V. MOSBY COMPANY 

1913 






Copyright, 1913, by G. V. Mosby Company. 



PRESS OF 

C. V. MOSBY COMPANY 

SAINT LOUIS 



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PREFACE TO SECOND EDITION 



The very generous reception which was given this book when 
first published was the best evidence that the profession was in 
need of such a work. 

The field of local anesthesia in anorectal surgery is well es- 
tablished, and in surgery generally is rapidly extending. The 
importance of a clear understanding of the diagnosis and treat- 
ment of anorectal diseases has forced itself upon the faculties 
of medical colleges and universities, with the result that an in- 
creasing number are giving regular courses in proctology. 

With the endeavor to make this work more valuable to the 
general practitioner, and to the student, who is the general prac- 
titioner of the future, this work has been completely revised. 
Operative technic has been further simplified, new diagnostic 
methods added, the use of quinin and urea anesthesia described ; 
the value of radiography in proctology illustrated by many plates ; 
numerous new illustrations, including two new color plates, have 
been added to more clearly assist the reader to follow out the 
various procedures described in the text. 

In the preparation of this edition the author wishes to extend 
his thanks to Dr. P. M. Hickey, Roentgenologist to Harper Hos- 
pital, who made all of the radiographs, and to the artists Tom 
Jones of St. Louis, and Norman Saxon Chamberlin of Detroit. 

The author also wishes to express his renewed appreciation 
of the eflforts of all those who assisted in no small degree in 
making the first edition possible. 

Louis J. Hirschman. 
January 5, 1913. 



PREFACE TO FIRST EDITION 



In presenting this book to the medical profession, the author 
does so with the feeling that it will be of some assistance to that 
great mass who were as unfortunate as he in their early college 
training in the special field of proctology. Diseases of the rec- 
tum and anus have been, and still are, in a great many colleges, 
dismissed with a single lecture or two, delivered as a part of the 
course on general surgery. The young graduate in medicine 
leaves his Alma Mater with a hazy idea that occasionally patients 
may suffer from "piles or fistula," and an operation under gen- 
eral anesthesia is their only hope of relief. 

The fact that the profession as a whole has been so remiss in 
the treatment of patients suffering from rectal diseases has left 
the field in the past to the quack and the irregular. 

A few earnest practitioners, however, in different parts of the 
country, gradually discovered that there was something more to 
rectal diseases than the treatment of ''piles and fistula," and 
began the scientific study of the lower bowel with the result that 
today the special field of proctology is firmly established with 
conscientious workers in all parts of the world. The results or 
the work of some of these men have been given to the world in 
the shape of most complete textbooks on the subject. In many 
of these works, however, the subject has been treated from the 
standpoint of the specialist in rectal diseases, and written for 
those who wish to follow that line of practice. 

With the introduction of local anesthesia into the treatment 
of diseases of the rectum and anus, a new field of work has been 
opened. Those patients suffering from many diseases of this re- 
gion, who have sought the advice and care of the irregular and 
the advertising quack, have done so on account of their dread 
of hospitals, general anesthesia, and "the knife." 

In order that the general practitioner may be qualified to 
diagnose and treat his patient who is suffering from anorectal 



6 PREI^ACK 

diseases as scientifically and as successfully as he does affections 
of other organs and localities, the author presents the results of 
his experiences in the treatment of anorectal diseases. 

The diagnosis of disease originating in this region has been 
dwelt upon to emphasize the importance of early examination. 
Illustrations, for the most part original, have been used wherever 
it has been thought necessar}^ to supplement the text for the 
sake of clearness. 

Non-surgical methods are described in those conditions where 
they have been found of value, and the technic of operative 
measures under local anesthesia has been made as simple as pos- 
sible. Only those conditions which are amenable to treatment in 
office practice have been discussed, and the limitations of office 
treatment clearly set forth. For information regarding those 
operative measures that are only applicable under general anes- 
thesia, and the consideration of those diseases whose treatment 
requires confinement in bed, the reader is referred to the 
several complete works on proctology that are now available. 

Those physicians living and practicing in the Southern states, 
particularly, will appreciate the inclusion in this work of a 
chapter on Dysentery. The author has been exceedingly for- 
tunate in securing the services of a man to prepare this chapter, 
than whom there is no one better posted on the subject: Dr. 
John L. Jelks, of Memphis, Tenn., President of the American 
Proctologic Society. 

Inasmuch as a very important index to the condition of the 
entire digestive tract and its functions is found in the excretions ; 
and the fact that the examination of the stools, which is fully 
as important as the urinary analysis, has been too long neglected, 
a chapter on the examination of the feces has also been included. 
Dr. George W. Wagner, of Detroit, Attending Physician to 
Harper Hospital, Gastroenterologist to the German Polyclinic, 
and Clinical Professor of Medicine in the Detroit College of 
Medicine, has kindly contributed this chapter, and the author con- 
siders himself extremely fortunate in securing the assistance of 
so well qualified a man. 

To the above named gentlemen; to Dr. Robert C. Jamieson, 
of Detroit, Dermatologist to Harper Hospital Polyclinic, who 
made the excellent photographs under the author's direction; to 



PREFACE 7 

Mr. James T. Nolan, the artist of Western Reserve University 
Medical Department, of Cleveland, O., who made all of the 
drawings; to the J. F. Hartz Co., of Detroit, who furnished the 
illustrations of many of the surgical instruments; to the pub- 
lishers for their hearty and willing co-operation; and lastly, to 
the many members of the medical profession through whose 
courtesy the author has been able to treat the large number of 
cases, the results of his experience with them having furnished 
the basis for the preparation of this work — the author extends his 
sincere and heartfelt thanks. 

Besides the results of his own experience, the author has 
availed himself of the privilege of consulting many of the recent 
works and textbooks on the subject of proctology, among which 
may be mentioned those of Tuttle, Gant, Matthews, Martin, 
Ball, Cripps, Wallis, and Hertz, as well as many articles by 
other authors appearing in the current literature of the day. 

If the author has succeeded in so simplifying the diagnosis 
and treatment of many of the more common diseases of the 
rectum and anus that this work will be of some assistance to the 
busy general practitioner in his every-day work, and has as- 
sisted in even a small degree in broadening the scope of the use 
of local anesthesia in this field, he will feel that he has accom- 
plished all that he set out to do. This modest work does not pre- 
tend or aspire to take the place of a textbook on the whole sub- 
ject of proctology, but if it will find a place on the physician's 
desk as a working handbook, the author feels that it will fill a 
long- felt want. 

Louis J. Hirschman. 

604 Washington Arcade. 

Detroit, Jan. 11, 1909. 



CONTENTS 



CHAPTER I. 
ANATOMY. 
Anus — ^Anal Canal — Rectum — Levator Ani — Ischiorectal Fossa 
— Sigmoid — Colon — Blood Supply — Lymphatics — Nerve Sup- 
ply 17-29 

CHAPTER n. 

SYMPTOMS WHICH SHOULD CALL ATTENTION TO 

THE RECTUM. 

Pain — Tenderness — Spasm — Bleeding — Itching — Protrusions — 
Elevations — Discharge — Constipation — Diarrhea — Altered 
Stools — Sacral Backache — Shooting Pains Down the Limbs — 
Crampy, Painful, and Scanty Menstruation — Urinary Disturb- 
ances — General Disturbances — Anemia — Restlessness in Chil- 
dren—Foreign Body 30-35 

CHAPTER HI. 
EXAMINATION OF THE PATIENT. 

Rooms and Furniture — Examination 36-65 

CHAPTER IV. 
CONSTIPATION AND OBSTIPATION. 
Physiology of Defecation — Etiologic Factors — Diagnosis — Treat- 
ment — Obstipation 66-95 

CHAPTER V. 

FECAL IMPACTION. 

Causes — Sjmaptoms — Diagnosis — Treatment 96-99 

CHAPTER VI. 

PRURITUS ANI. 

Causes — Diagnosis — Treatment 100-116 

9 



10 CONTENTS 

CHAPTER VII. 

ANAL FISSURE AND ULCER. 

Cause — Diagnosis — Treatment — ^Anal Ulcer 117-128 

CHAPTER VHL 
ABSCESS OF THE ANORECTAL REGION. 
Tegumentary Abscess — Subtegumentary or Marginal Abscess — Sub- 
mucous Abscess — Ischiorectal Abscess 129-140 

CHAPTER IX. 
ANAL FISTULA. 
Varieties of Fistula — Simple Complete Fistula — Blind External 
Fistula — Blind Internal Fistula — Submucous Tract — Submu- 
cous or Mucocutaneous Fistula — Injection of Bismuth Paste 
— Anal Fistula in the Tuberculous Patient 141-158 

CHAPTER X. 

HEMORRHOIDS. 

Varieties — Causes — Symptoms — Diagnosis — Treatment 159-190 

CHAPTER XI. 
RECTAL POLYPI— HYPERTROPHIED ANAL PAPILL^- 

CRYPTITIS. 

Polypus — Hypertrophy of the Anal Papillss — Cryptitis^ 191-200 

CHAPTER XIL 
PROCTITIS AND SIGMOIDITIS. 
Acute Proctitis and Sigmoiditis — Chronic Proctitis and Sig- 
moiditis 201-213 

CHAPTER. XIII. 
DYSENTERY. 
General Considerations — Acute Catarrhal Dysentery or Sporadic 
Bacillary Dysentery — Diphtheritic Dysentery — Secondary 
Diphtheritic Dysentery — Amebic Dysentery — Chronic or 
Secondary Amebic Dysentery 214-253 



conte:nts 11 

CHAPTER XIV. 

PROLAPSE OF THE RECTUM IN CHILDREN. 

Etiology — Symptoms — Diagnosis — Treatment 254-262 

CHAPTER XV. 

TECHNIC OE THE USE OF LOCAL ANESTHESIA IN 

THE TREATMENT OF ANORECTAL DISEASES. 

Anesthetic Agents — Instruments — General Technic — Technic in 

Special Cases 263-280 

CHAPTER XVI. 

LIMITATIONS OF LOCAL ANESTHESIA AND OFFICE 

TREATMENT AND INDICATIONS FOR 

OTHER MEASURES. 

General Contraindications to Local Anesthesia — Cancer of the 
Rectum — Ulceration of the Bowel — Stricture of the Rectum — 
Rectal Abscesses — Anal Fistula — Hemorrhoids — Prolapse of 
the Rectum — Removal of Concretions — Fistulse Communicat- 
ing with other Organs 281-292 

CHAPTER XVII. 
THE FECES AND THEIR CLINICAL EXAMINATION. 

General Characteristics of Feces — Clinical Examination of the 
Stools — Microscopic Examination — Chemical Examination — 
Clinical Significance of Test — Animal Parasites — Character of 
Feces in Certain Intestinal Affections 293-321 

Index of Authorities Quoted 

Index 



ILLUSTRATIONS 

Plate I. Cancer of the rectum complicating prolapsing hemor- 
rhoids Frontispiece 

Plate II. Blood vessels of the rectum Facing page 28 

Plate III. Giant sigmoid colon Facing page 78 

Plate IV. Section of intestine below ulceration Facing page 230 

FIG. PAGE 

1. Rectum and anal canal in the male 18 

2. Rectum hardened in formalin 21 

3. Proctoscopic view of rectal valves 22 

4. Muscles and nerves of the male pelvic outlet 24 

5. Simple form of instrument sterilizer 37 

6. Small instrument and dressing sterilizer 37 

7. Columbus operating-table 38 

8. Electric magnifying headlight 39 

9. Simple form of record card 40 

10. Reverse side of record card 40 

11. External inspection 41 

12. Method of applying lubricant from collapsible tube 42 

13. Incorrect method of digital examination 43 

14. Correct method of digital examination 44 

15. Vaginal eversion of the anus 45 

16. Another method of everting anus 4G 

17. Amount of possible eversion of anal tissues 47 

18. Method of examining the coccyx with one hand 48 

19. Rectoabdominal bimanual examination 49 

20. Rectoabdominal palpation 50 

21. Palpation of rectum through posterior vaginal wall 50 

22. Ischiorectal abscess 51 

23. Squatting position 52 

24. Three-ounce, all-rubber bulb syringe 52 

25. Knee-elbow position 53 

26. Knee-shoulder position 53 

27. Author's anoscope with oblique opening 54 

28. Author's adjustable fenestrated anoscope 54 

29. Silver probe 55 

30. Long alligator forceps 55 

13 



14 II.I.USTRATIONS 

riG. PAGE 

31. Kelly anoscope 56 

32. Method of using author's fenestrated anoscope 57 

33. Author's modification of Martin proctoscope 58 

34. Exaggerated lithotomy position 59 

35. Kelly sigmoidoscope 60 

36. Sigmoidoscope with author's tilting obturator 61 

37. Inverted or Hanes' position 61 

, 38. Imperforate anus in one-year-old child 62 

39. Atresia ani vaginalis (complete) 63 

40. Atresia ani vaginalis (incomplete) 64 

41. Normal segmentation of colon up to splenic flexure 75 

42. Overdistention of ascending cecum and transverse colon... 76 

43. Megacolon 77 

44. Megacolon, after removal 78 

45. Coloptosis with angulation and adhesion of transverse colon . . 79 

46. Bismuth meal passing from ilium to cecum 80 

47. Whole colon injected with bismuth 81 

48. Ptosis of cecum 82 

49. Ptosis of cecum 83 

50. Author's dilating rectal massage bag 86 

51. Author's dilating rectal massage bag (deflated and inflated) 87 

52. Position for author's method of rectal massage.. 88 

53. Author's four-inch operating proctoscope 92 

54. Author's rubber ligature carrier 92 

55. Author's angular rectal scissors 92 

56. Technic of author's operation for rectal valvotomy 93 

57. Author's rubber ligature operation 94 

58. Pruritus ani 102 

59. Pruritus ani, showing excoriation 103 

60. External hemorrhoids with pruritus ani 104 

61. A simple and satisfactory rectal dressing Ill 

62. Sharp-pointed scissors curved on the flat 112 

63. T-forceps 112 

64. Ball's operation for pruritus ani — lines of incision 113 

65. Ball's operation for puritus ani — dissecting the flap 114 

66. Ball's operation for pruritus ani — area of anesthesia 115 

67. Krouse's radiating incisions for Ball's operation 116 

68. Anal flssure, showing sentinel pile 117 

69. Multiple anal flssure 118 

70. Anal fissure from crypt of Morgagni 119 

71. Applying ointment to anus from lead tube 122 

72. Injection of anal fissure 123 

73. Simple incision of fissure 124 

74. Sharp-toothed or pronged forceps 125 

75. Author's technic for incision of anal fissure 126 

76. Operation for excision of anal ulcer 127 



II.I.USTRATIONS 15 

FIG. PAGE 

77. Anorectal abscesses 130 

78. Characteristic sitting posture in anorectal disease 132 

79. Proctoscopic view of submucous abscess 135 

80. De Vilbiss rectal speculum 136 

81. Line of incision for ischiorectal abscess 138 

82. Anorectal fistulse 143 

83. Direct complete anal fistula 144 

84. Angular fistulous tract 144 

85. Radiograph of simple direct complete fistula 145 

86. Complicated complete fistula 146 

87. Multiple fistula communicating with urethra 147 

88. Grooved director 148 

89. Incision for simple direct anal fistula 149 

90. Author's technic for removing fistulous tract 150 

91. Technic of ligature operation for fistula 152 

92. Interno-external hemorrhoids 160 

93. Section of interno-external pile 161 

94. Acute external thrombotic hemorrhoid 162 

95. External thrombotic hemorrhoids 163 

96. External cutaneous hemorrhoids 164 

97. Single prolapsing internal hemorrhoid 165 

98. Prolapsing internal hemorrhoids 166 

99. Prolapsing internal hemorrhoids 167 

100. Prolapsing internal hemorrhoids 168 

101. Bivalve rectal speculum 169 

102. Injection of interno-external hemorrhoid 177 

103. Injection of prolapsing hemorrhoid 178 

104. Prolapsing interno-external hemorrhoids, anesthetized 179 

105. Injection of prolapsing pedunculated internal hemorrhoids.. 180 

106. Author's hemorrhoidal forceps 181 

107. Rectal rectractor modified from Sims' speculum 182 

108. Author's blunt-pointed ligature carrier 182 

109. Internal hemorrhoid anesthetized 183 

110. Technic of author's bloodless operation 184 

111. Technic of author's bloodless operation 185 

112. Distention of external hemorrhoids with sterile water 189 

113. Rectal polypus 192 

114. Hypertrophy of anal papillae and crypts of Morgagni 194 

115. Hypertrophied anal papillaa 195 

116. Proctoscopic view of hypertrophied anal papillae 197 

117. De Vilbiss spray tube 203 

118. Author's rectal spray tube 204 

119. Spraying rectum in knee-shoulder position 205 

120. Ulcer of the rectum 210 

121. Amoeba histolytica 222 

122. Amoeba coli mitis 223 



16 II.I.USTRATIONS 

FIG. PAGE 

123. Slough of mucous membrane 227 

124. Edge of intestinal ulcer 228 

125. Dysenteric ulceration on the valves of Houston 229 

126. Photograph of case, Mr. A. R. C , 235 

127. The Jelks' irrigating tube 245 

128. Position for irrigation of colon with Jelks' tube 247 

129. Position for introduction of colon tulJe 248 

130. Method of application of solutions to rectum and sigmoid... 250 

131. Method of spraying rectum and sigmoid 251 

132. Prolapse of the rectum, third degree 255 

133. Prolapse of the rectum, first degree 260 

134. Aseptic all-glass hypodermic syringe 268 

135. Aseptic all-metal syringe 269 

136. Point of puncture for injecting local anesthetics 270 

137. Quadrants of the anus 281 

138. Amount of distention for anesthetizing sphincters 272 

139. Point of puncture for anesthetizing sphincterian nerves.... 273 

140. Producing dilatation of sphincters with vibrator 274 

141. Amount of dilatation of sphincter 275 

142. AVales rectal bougie 279 

143. Proctoscopic view of carcinoma 284 

144. Carcinoma after removal by operation 284 

145. Cancer of the rectum, with multiple fistulae 285 

146. Cancer of the rectum 286 

147. Cancer of the rectum, interior view 287 

148. Sulphid of bismuth crystals from the stools 295 

149. Collective view of the feces 296 

150. Muscle remnants in feces 299 

151. Steele's modification of Strassburger's fermentation apparatus 300 

152. Mucus shreds 302 

153. Mucus shreds after the addition of acetic acid 302 

154. Hematoidin crystals from acholic stools 303 

155. Acholic stools 303 

156. Gallstones 307 

157. Amoeba coli 308 

158. Balantidium coli 309 

159. Ascaris lumbricoides 310 

160. Oxyuris vermicularis 311 

161. Oxyuris vermicularis 312 

162. Ankylostomum duodenale 313 

163. Trichocephalus dispar 314 

164. Trichinae 315 

165. Anguillula stercoralis 316 

166. Head of Taenia solium 317 

167. Taenia saginata 318 

168. Head of Bothriocephalus latus 319 



CHAPTER I. 
ANATOMY. 

It is not the intention in a work of this scope to go into minor 
anatomical details in the description of the anus and rectum. It 
is essential, however, that one who intends to treat even the 
most common and uncomplicated diseases of the anus and rectum 
should have a practical working knowledge of the gross anatomy 
of the anorectal region. 

In reversing the usual order of describing these organs, the 
author starts with the anus first, because it is to the anal orifice 
that one's attention is first directed in proceeding to examine or 
operate for diseased conditions affecting these organs. It appears 
to the author, therefore, that the anatomy of these organs should 
be described in the order in which they are met : from with- 
out, inward. 

ANUS. 

The anus is an oval aperture, longitudinal when in repose, 
situated at a point equidistant from the tuberosities of the ischii, 
and about one inch anterior to the tip of the coccyx. In the fe- 
male it is situated a little more anteriorly than in the male. The 
anus is surrounded by integument which is slightly darker than 
the surrounding skin. The skin around the anus is arranged in 
radiating folds caused by the contraction of the cormgator cutis 
ani muscle. The circumanal integument contains sweat glands, 
sebaceous glands, and hair follicles. The circumference of the 
anal orifice varies from an inch to an inch and three quarters, 
but it may be dilated to a circumference five or six times greater. 

ANAL CANAL. 

The anal canal extends from the point at which the sides of the 
anal aperture first appose to the linea dentata or lower edges of 
the semilunar valves, which guard the openings of the crypts of 
Morgagni. Its depth varies from two thirds of an inch to an 
inch and a quarter. It is lined by a membrane composed of thin 

17 



18 



DIS^ASE^S Olf THE RECTUM 



/^ 




S.E. 



Fig. 1. Rectum and anal canal in the male — longitudinal section. 
(Section made by Professor A. F. Dixon of a formalin-hardened male 
pelvis.) — After Ball. 

B. C. Bulbocavernosus muscle. 

B. Bladder. 

P. Prostate gland. 

R. U. Rectourethralis muscle. 

S. V. Seminal vesicle with ejaculatory duct below. 

S. I. Internal sphincter muscle. 

S. B. External sphincter muscle. 

A. Anus. 

P. R. Puborectalis muscle, around which the rectum bends sharply, 
to be continued into the anal canal. 

R. Rectum. 



ANATOMY 19 

transitional epithelium, gradually changing in histological forma- 
tion from the stratified cells of true skin at the anus to the goblet- 
cells of mucous membrane at its juncture with the rectum at the 
linea dentata, or anorectal line. Surrounding the lining membrane 
is one of cellular tissue, and beneath this the muscular layer com- 
posed of the external sphincter, a few fibers of the levator ani, 
and the lower portion of the internal sphincter. The dimensions 
of the anal canal, when in repose or dilated, are slightly smaller 
than those of the anus itself in like condition. The lining mem- 
brane presents to the eye a pinkish-red shining appearance, in 
some cases a more or less purplish hue (Fig. 1). 

External Sphincter Muscle. — This is the most important 
muscle with which we have to deal from a surgical point of view, 
and is the principal muscular structure which goes to form the 
anal canal. It is composed of circular and longitudinal fibers. 
The longitudinal arise from the lower end and posterior aspect 
of the coccyx, and surrounding the anus in an elliptical manner, 
meet and are inserted into the central tendon of the perineum. 
The circular fibers are more superficial, entirely surrounding 
the anal canal. The muscle is norm.ally in a state of contraction, 
keeping the anus closed, and it is of great importance in the 
voluntary control of the act of defecation. Its nerve supply is 
derived from the third and fourth sacral and superficial branch of 
the internal piidic and a filament of the fifth and sixth sacral, 
known as the lesser sphincterian nerve. This nerve is of ex- 
treme importance in the production of local anesthesia for the 
dilatation of the anus. It enters the external sphincter on either 
side at a point at the juncture of the lower and middle third of 
the anus. 

At the upper limit of the anal canal at its juncture with the 
lower portion of the rectum are situated the anal papillce and 
crypts of Morgagni. The papillae appear as a more or less dis- 
tinct line of small saw-tooth-like triangular projections which en- 
circle the anal canal. This line is called the linea dentata, or 
anorectal line. Just behind these papillae are found the openings 
of the crypts of Morgagni. The anal papillae and crypts of 
Morgagni are of especial interest because they are often the seat 



20 DISEASES 0^ THE RECTUM 

of inflammatory conditions which present symptoms often out of 
all proportion to the size of the lesion causing them. 
The blood and lymphatic supply will be taken up later. 

RECTUM. 

The rectum is a hollow, tubular organ varying in length from 
five to seven inches, and extending upward from the anorectal ' 
line to the rectosigmoidal juncture (Fig. 2). When empty, its 
anterior and posterior walls appose, and a cross-section would 
show a transverse slit. The rectum is usually understood to be 
that portion of the lower end of the large intestine which extends 
from the left sacroiliac symphysis to the anorectal line. Instead 
of it being a straight canal, as its name indicates, it is curved 
backward from the anorectal line, following the hollow of the 
sacrum, curving forward at the promontory, where it joins the 
lower portion of the sigmoid flexure. Some authors describe the 
rectum as that portion which extends from the anorectal line 
to the third sacral vertebra, which includes that portion which is 
not covered by peritoneum, the part above this being called the 
lower end of the pelvic colon, or sigmoid colon. Inasmuch as this 
latter division has not been accepted as yet, the author will con- 
sider the rectum as described in all of the standard textbooks on 
anatomy. 

We will consider the rectum as divided in two portions : the 
upper or peritoneal portion ; and the lower or that portion below 
the third sacral vertebra, the extraperitoneal. Thomas Charles 
Martin divides the rectal cavity into first, second, and third rec- 
tal chambers, each chamber corresponding to that portion below 
one of the rectal valves or folds of Houston. 

The rectum is composed of four coats, being from within out- 
ward : the mucous, submucous, muscular, and serous. The mus- 
cular coat is composed of both circular and longitudinal fibers. 
At the lower portion of the rectum and extending down to the 
white line of Hilton in the anal canal, the circular muscular 
fibers are more numerous and thrown together into what is known 
as the internal sphincter muscle. The mucous membrane is 
gathered together in folds which converge at the anorectal line, 
ending at the crypts of Morgagni. These folds are known as the 



ANATOMY 



21 




Fig-. 2. Rectum hardened in situ with formalin and then dissected 
out. — After Ball. 

S. Sacral curve of rectum. 

P. Peritoneum cut at reflexion from bowel. 

R. Portion of rectum uncovered by peritoneum. 

D. Pelvic diaphrag-m. 

E. External sphincter. 



22 DISE:aSE:S 0^ THE RECTUM 

columns of Morgagni. With the patient in the knee-shoulder 
position and the rectum inflated, the circumference of the organ 
when dilated will vary from five to ten inches. With the rectum 
inflated certain definite crescentic folds will be seen standing out 
from the rectal Vv^all, encircling it for from one third to two 
thirds of its circumference. They appear at definite points and 
are usually three in number. One extremity appears attached 
lower to the rectal wall than the other, and they are arranged in 
such a manner that on proctoscopic view they give the effect of 
three projecting ledges arranged in the form of a spiral; the sec- 
ond being attached an inch to an inch and a half above the middle 
of the first ; and the third at a point about the same distance 




Fig. 3. Proctoscopic view of the rectal valves — semidiagTammatic. 

above the middle of the second (Fig. 3). The first rectal valve, 
or fold of Houston, as it is called, is situated more often on the 
left lateral wall of the rectum opposite the location of the prostate 
gland, while the third is at or below the rectosigmoidal juncture. 
These valves are not simple folds of mucous membrane, but con- 
tain muscular fibers and blood-vessels and present all the charac- 
teristics of a typical anatomical valve. They are of considerable 
interest and importance because of the fact that, when they are 
infiltrated, thickened, or enlarged, they offer more or less ob- 
struction to the passage of the fecal current and ulcerations con- 
cealed on their upper surfaces are often overlooked, whose dis- 
covery would clear up the etiology of many so-called cases of 
diarrhea. ; 



ANATOMY 23 

LEVATOR ANI MUSCLE. 

Except the external sphincter muscle this is the most 
important muscle with which v/e have to deal (Fig. 4). With 
the external sphincter, this muscle practically controls the act of 
defecation. During defecation the levator ani and external 
sphincter muscles are relaxed, and the feces are extruded by the 
involuntary action of the muscular coats of the bowel, assisted 
by the voluntary compression and contraction of the abdominal 
muscles. The internal sphincter, in all probability, does not act 
as a sphincter at all, but co-operates in the peristaltic movement 
of the internal muscular coat of the intestine. When the fecal 
mass is extruded, the anterior portion of the upper portion of the 
anal canal is fixed by the rectourethralis muscle, which is a 
definite muscular band by which the anterior surface of the bowel 
at the juncture of the rectum and anus is connected with the 
urethra. The puborectalis portion of the levator ani then com- 
presses the sides and draws the posterior portion of the opening 
toward the pubis. 

The external sphincter then completes the evacuation and closes 
the anal canal. 

The levator ani, as described by Thompson and Ball, is com- 
posed of three main portions, the iliococcygeus, pubococcygeus, 
and puborectalis. 

Iliococcygeus. — Although definitely attached to the ilium in 
many lower animals, in man this takes origin from the spine of 
the ischium and from a portion of the obturator fascia, roughly 
indicated by a white line which extends in a curve from the spine 
of the ischium to the back of the pubis. Although in older text- 
books this white line is described as a tendinous origin of the 
levator ani, recent observations tend to show that but few, if any, 
of the muscular fibers are actually attached to it, and that it is 
merely a thickening of the pelvic fascia. From this origin the 
iliococcygeus extends in a fan shape to be inserted into the side 
of the sacrum and coccyx; it is thin and in part membranous, 
and must be regarded as a degenerated muscle whose primary 
function in connection with the tail is lost, but in virtue of whose 
position contributes to the formation of the pelvic floor. It 
has no direct relation to the rectum. 



24 



DisMSKs 0^ Tut re:ctum 



Pubococcygeus. — This arises from the back of the pubis, and 
also from the obturator fascia, where usually its fibers blend with 
those of the iliococcygeus ; from the origin the fibers pass almost 




Fig-. 4. Muscles and nerves of the male pelvic outlet. — After Ball. 

T. P. Transversus perinei muscle. 

S. B. External sphincter muscle. 

G. M. Gluteus maximus muscle. 

L. A. Levator ani muscle. 

G. M. Gluteus maximus muscle. 

C. Coccyx. 

I. H. Inferior hemorrhoidal nerve. 

A. Anus. 

P. P. Posterior superficial perineal nerve. 

C. T. Central tendinous point of perineum. 

B. C. Bulbocavernosus muscle. 



ANATOMY 25 

horizontally back, overlapping the iliococcygeus, closely related 
to the rectum (and vagina), to be attached to the coccyx and 
anococcygeal ligament. A few of the anterior fibers descend in 
front of the rectum to the perineal body, while lateral fibers are 
continued down into the aponeurotic sheath which surrounds the 
anal canal, in which the longitudinal fibers of the external coat 
of the rectum terminate. 

Puborectalis, or Sphincter Recti. — This is the name given by 
Holl to an important band of fibers of the pubococcygeus, which, 
instead of being inserted into the coccyx and its ligamentous 
connections, is continuous with the fibers of the same muscle on 
the other side, forming a strong muscular cord around the lateral 
and posterior aspects of the upper opening of the anal canal. 
The fibers of the puborectalis muscle arise from the back of 
the pubis on either side, under cover of the pubococcygeus, and 
pass between the layers of this muscle, with more or less inter- 
change of fibers, to the back of the rectum, where they are con- 
tinuous with the fibers of the same muscle on the other side. It 
is the most muscular portion of the levator ani, and when removed 
from a formalin-hardened body leaves a deep groove posteriorly 
where the rectum turns abruptly into the anal canal. According 
to Thompson, although traces of this muscle are found in some 
lower animals, it is only in the anthropoids that we find a muscu- 
lar sling strongly developed for the first time, which in man has 
become evolved into such an important structure. 

LIGAMENTS. 

The chief ligaments that assist in supporting the rectum are 
the anococcygeal and lateral ligaments. The anococcygeal is a 
cord-like ligament which extends from the tip of the coccyx to a 
point near the juncture of the anus and rectum on its posterior 
surface. Attached to it are some of the more superficial fibers of 
the external sphincter. Upon either side of the rectum, just be- 
neath the lateral reflections of the peritoneum, are connective- 
tissue attachments known as the lateral ligaments of the rectum. 
It is important to remember that they contain the middle hemor- 
rhoidal vessels. 



26 Dis^AS^s 0-^ the: rejctum 

RELATIONS OF THE RECTUM. 

The upper half of the rectum is almost entirely surrounded by 
peritoneum. In front the peritoneum dips down between the 
rectum and bladder, forming what is known in the male as the 
rectovesical pouch; in the female the uterus and vagina take the 
place of the bladder, and the pouch is known here as Douglas' 
pouch. The distance between the anus and the deepest point of 
dipping of this pouch is of great importance in the surgery of 
this region, and the distance varies, according to the measure- 
ments of different authors. The average distance is given as four 
inches. Cripps, after careful measurements of a large number 
of cadavers, gives the distance as 2^/2 inches when the bladder 
and rectum are emptied, and 3^ inches when both are distended. 
From this lowest point on the anterior surface of the rectum, the 
peritoneum gradually invests more and more of the rectum until 
its upper portion at the posterior wall of the rectum is about 
1^ inches higher than the anterior. Where the two folds of 
peritoneum come together behind the rectum, they form a com- 
plete mesentery which is continuous with that of the sigmoid. 

Other relations of the rectum are in front with the bladder, 
seminal vesicles, vas deferans, urethra, and prostate in the male ; 
and the vagina, litems, and adnexa in the female. Posteriorly it 
lies against the hollow of the sacrum and the coccyx. Laterally its 
upper portion is oftentimes in close contact with coils of the 
small intestine when they descend into the pelvis. On either 
side of the lower half of the rectum are located the ischiorectal 
fossce. 

ISCHIORECTAL FOSSA. 

The ischiorectal space, or fossa, is a triangular space filled with 
loosely organized connective tissue and fat, situated on either side 
of the rectum between it and the tuberosity of the ischium. The 
apex of the cavity is directed upward and the base toward the 
perineum. 

Gant describes these fossae as follows: 

"Their depth varies from one and a half inches in front to 
two inches behind, and at their lowermost and broadest part they 
are a little more than an inch in width. Internally these spaces 



ANATOMY 27 

are in relation to the external and internal sphincters, coccygeus, 
and levator ani muscles ; externally with the tuber ischii and ob- 
turator fascia; anteriorly with superficial and perineal fasciae; 
and posteriorly with the border of the gluteus maximus muscles,, 
the investing fascia of which is continuous with the great sacro- 
sciatic ligament. Within a sheath formed by the obturator fascia 
are to be found the internal pudic artery, veins, and nerv^es. The 
inferior hemorrhoidal vessels and nerves pass through the central 
portion of the ischiorectal fossae on their way to the anal canal to 
which they are distributed, while in the anterior portion of these 
spaces are the superficial perineal vessels and nerves. The fat 
and connective tissue filling these spaces act as elastic supports for 
the rectum and are largely responsible for the lateral walls of 
the rectum remaining in contact. These fossae are of surgical 
importance because of the frequency with which abscesses and 
fistulae are found in this locality." 

SIGMOID COLON. 

The sigmoid colon is that portion of the large intestine extend- 
ing from its juncture with the rectum at the left sacroiliac 
symphysis to a point opposite the crest of the ileum where it be- 
comes continuous with the descending colon. It derives its name 
of sigmoid colon or flexure from its double curve. It is entirely 
a peritoneal organ and is attached by a mesentery which is known 
as the mesosigmoid. Its average length is from 18 to 20 inches. 
When empty, the greater portion of the sigmoid colon lies in the 
left iliac fossa, and a portion of it may dip down into the pelvis. 
When filled, it usually extends over and occupies the right iliac 
fossa as well as the left. It is composed of four coats correspond- 
ing to those of the rectum, and in addition has on its outer surface 
directly opposite to its mesenteric attachment a longitudinal mus- 
cular band. Its narrowest portion is at its juncture with the 
rectum. On account of the length of its mesocolon, the sigmoid 
is of importance because of its tendency in some cases to prolapse 
or become invaginated into the rectum. 



28 DISE^ASE^S OF THE^ RE^CTUM 

BLOOD SUPPLY (Plate II). 

The arteries of the rectum are the superior, middle, and in- 
ferior hemorrhoidal, and occasionally a branch from the middle 
sacral and the vesical. The largest and most important vessel 
is the superior hemorrhoidal, which is a direct continuation of 
the inferior mesenteric. This vessel, which is situated at the 
posterior portion of the rectum, slightly to the left of the median 
line, passes down from the mesentery of the sigmoid colon to the 
upper portion of the rectum at a point about 4 to 4^/2 inches from 
the anus. It here divides into two main branches, the right and 
left, which almost immediately subdivide into three or four 
smaller branches, which run down the rectum almost to the anus, 
connected by a number of anastomotic branches, some of which 
pass in through the muscular coat of the bowel to the submucous 
coat where they end in a number of terminal branches, one being 
usually found in each of the columns of Morgagni. The middle 
hemorrhoidal artery arises from the internal iliac and enters the 
rectum on either side through the lateral ligament, where it breaks 
up into a number of branches, which supply the outer coats of 
the bowel but not the mucous membrane. The inferior or ex- 
ternal hemorrhoidal arises from the internal pudic, and passing 
through the ischiorectal fossa, is distributed to the muscles of the 
anal canal. This artery supplies the cutaneous portion of the 
anus, the skin surrounding the margin of the anus, but not the 
mucous membrane. 

Venous Supply. — The veins of the rectum follow the arteries. 
The superior hemorrhoidal vein returns the blood from the rectum 
into the inferior mesenteric vein and directly to the portal circu- 
lation. Like the rest of the portal system, the superior hemor- 
rhoidal vein is not supplied with valves. The middle and in- 
ferior hemorrhoidal veins return the blood from the anus and 
circumanal region by way of the internal iliac into the general 
venous circulation. The hemorrhoidal plexus is composed of a 
large number of anastomosing veins situated in the submucous 
and subcutaneous tissues of the anal canal, and is emptied largely 
by the superior hemorrhoidal veins. 



p. 



E. S. 




S. H. 



\\. H. 



J. H. 



PLATE II. 

Blood-vessels of the i^ectum. — After Ball. 

S. H. Superioi' hemorrhoidal artery. 

M. H. Middle hemorrhoidal artery. 

I. H. Inferior hemorrhoidal artery. 

A. Anus. 

E. S. External sphincter muscle. 

P. D. Pelvic diaphragm. 

P. Cut edge of peritoneum. 



ANATOMY 29 

LYMPHATICS. 

The lymphatic vessels from the mucous membrane of the rec- 
tum proper communicate with a number of small glands known 
as the postrectal glands, lying between the rectum and the sac- 
rum, from which lymphatic vessels pass up into the mesentery 
of the sigmoid. The lymphatics from the skin of the anus and 
circumanal region communicate by the inner surface of the thighs 
with the inguinal glands. An important point to remember in this 
connection is that early involvement of the inguinal glands would 
indicate disease, either malignant or infections, situated in the 
anal region, while malignant or infectious diseases of the rectum 
proper would extend to and infiltrate the presacral or postrectal, 
lumbar, and mesenteric glands. 

NERVE SUPPLY. 

The rectum is not supplied with sensory nerves, particularly 
in its upper half. The anus and anal canal and lower portion of 
the rectum, on the contrary, are liberally supplied. This accounts 
for the comparative absence of pain when the rectum proper is 
diseased, and the intense suffering caused by lesions in the anal 
canal. The sensory nerves of the anus are derived from the 
sacral plexus. The external sphincter muscle receives its nerve 
supply by branches from the sacral plexus, especially the tJiird 
and four til nerves. The lesser sphincterian nerve of Morestin, 
which is one of great importance in the production of local 
anesthesia for the dilatation of the external sphincter, is described 
by Tuttle as: "A filament coming off from the fifth and sixth 
sacral nerves which passes down the hollow of the sacrum through 
the levator ani muscle and the rectococcygeus ligament, finally 
reaching the posterior superficial surface of the external sphincter 
muscle." The levator ani is also supplied by branches from the 
sacral plexus. While the anus and rectum both receive their 
nerve supply from the sympathetic and cerebrospinal systems, the 
principal nerve supply of the rectum proper is sympathetic, it 
receiving branches from the mesenteric, sacral, and hypogastric 
plexuses. From the cerebrospinal system it is supplied by some 
filaments from the third, fourth, and fifth sacral nerves. 



CHAPTER II. 

SYMPTOMS WHICH SHOULD CALL ATTENTION 
TO THE RECTUM. 

It has been estimated that one patient out of every seven is 
suffering from some disease, the reHef of which would be as- 
sisted, or entirely accomplished, by the treatment of pathological 
conditions discovered only upon rectal examination. Many pa- 
tients consult a physician, whose localized pain, swelling, hemor- 
rhage, discharge, tenderness, irritation, or other symptoms call 
attention at once to the anorectal region. Many other symptoms, 
however, of a more general character — such as disturbances of 
digestion, menstruation, and the functions of urinary organs, as 
well as headache, backache, sciatica, anemia, and sometimes even 
asthma and acne vulgaris — are more remote evidences of diseases 
originating within the confines of the lower bowel. 

Pain. — This is the most frequent symptom which causes a 
patient to seek a physician's aid. It may be located at the anal 
orifice, in the anal canal, or the lower two inches of the rectum. 
It may be sharp, coming on suddenly, paroxysmal, burning, 
throbbing, or of a dull aching character. The character of the 
pain and the time of its onset with relation to the bowel move- 
ment are important, as they, of themselves, are often clues to the 
diagnosis. Sharp, acute pain, of a cutting, burning, or stinging 
quality, coming on with the stool or following it, almost invariably 
points to some lesion in the anal canal. Sudden, darting pains, oc- 
curring in the intervals between stools, also point to the same re- 
gion for their origin. Pain of a throbbing character indicates acute, 
or subacute, inflammatory conditions. These may be integu- 
mentary, perianal, or perirectal abscesses. In these latter condi- 
tions, a rise in temperature will be noted, and the blood examina- 
tion will show a leucocytosis. Pain of a dull aching character, 
whether intermittent or constant, may be caused by hemorrhoids, 
prolapse, polypus, fistula, ulceration of the rectum, benign growths 
— such as rectal adenoids — or malignant disease. 

Many diseased conditions of the rectal cavity may progress to 
an astonishing degree without causing any local pain on account 

30 



SYMPTOMS 01^ RECTAI. DISEASES 31 

of the lack of sensor}* innervation of this region. Pain, however, 
referred to other portions of the body — such as the sacrum, 
uterus, vagina, bladder, urethra, penis, scrotum, or down the 
sciatic nerves, or up into the inguinal region — is frequently 
caused by pathological conditions in the rectum, which cause no 
local pain whatever. 

Tenderness. — Tenderness in the circumanal region usually 
points to abscess formation or fistula. Tenderness of the anus 
indicates inflammatory conditions or ulceration. 

Spasm. — This is caused by anything which irritates the 
sphincter muscles. Anal fissure, ulcer, or abscess, as well as 
hypertrophied papillae, or foreign bodies, are the usual causes 
of anal spasm. 

Bleeding. — This is one of the most frequent symptoms ac- 
companying diseases of the anus and rectum, and it is one of 
the symptoms above all others which should call for complete 
examination of the anus, rectum, and sigmoid. Bleeding is more 
common in adults than in children. It may be very profuse, or 
slight, as simply a drop or two. It usually occurs during defeca- 
tion, but may occur during the intervals as well. The blood may 
be discharged either liquid or clotted. It may be pure, or mixed 
with mucus, pus, feces, or other debris. Fresh blood discharged 
from the anus is usually from a local hemorrhage, but may have 
descended from the sigmoid or colon. The darker in color the 
blood, the higher in the bowel its source. Rectal hemorrhage may 
be caused : 

1. By local disease. 

2. By traumatism. 

3. Following operation. 

The cause of the last is so evident that it will not be considered, 
and trauma will simply be mentioned. The local diseases of the 
rectum which m.ay cause hemiorrhage are : 

1. Internal hemorrhoids. 

2. Prolapse. 

3. Fissure. 

4. Ulceration. 

5. Stricture. 

6. Malignant disease. 

7. Proctitis. 



32 DISEASES O^ THE RECTUM 

8. Fecal impaction. 

9. Polypus. 

10. Villous growths. 

11. Chancroids and chancres. 

12. Condylomata. 

Other diseases causing local rectal hemorrhage are : 

1. Amebic dysentery. 

2. Intussusception. 

3. Embolism of mesenteric artery. 

4. Congestion of the portal vein. 

The general systemic diseases, such as malaria, scurvy, tuber- 
culosis, typhoid fever, and others, which may during their course 
give rise to bloody stools, are not considered in this work because 
the diseased condition is very evident long before the hemorrhage 
presents itself. It may be mentioned, however, that the passage 
of some mucus streaked with blood in typhoid fever is often a 
warning signal of impending hemorrhage, and perforation. 

The type of hemorrhage characteristic of the various condi- 
tions will be taken up as each variety is discussed in its respective 
chapter. The author has seen so many cases of cancer of the 
rectum, which had gone on to almost complete occlusion of the 
rectum and involvement of other organs, whose lives might have 
been saved if proper and complete examination of the rectum had 
been made when hemorrhage first manifested itself, that he is 
constrained to lay great stress on the importance of this symptom. 
Rectal hemorrhage^ no matter how slight, should never he taken 
for granted as diagnostic of hemorrhoids or any other disease, 
hut should call for a complete examination, the technic of which 
will be explained in the following chapter. 

Itching. — Itching of the anus, or of the perineum, scrotum, or 
vulva, is a frequent accompanying symptom of many anal and 
rectal diseases. In fact, it may occur with any of them. The 
degree and severity of the itching vary from a slight feeling of 
uneasiness and irritation, a mild pricking sensation following 
stools, to the most intense, persistent, aggravating condition char- 
acteristic of the more severe types of pruritus ani. Many con- 
stitutional diseases, such as diabetes and uric acidosis, predispose 
the patient to itching of any part of the body. When such a 
patient has a diseased condition of any part of the anorectal 



SYMPTOMS 01^ RECTAL DISEASES 33 

region, however slight, he usually develops pruritus ani in ad- 
dition to his other symptoms. In the author's experience, almost 
every case showing itching as the predominating symptom has 
been demonstrated to have had its origin in some local diseased 
condition of the anorectal region. 

Protrusions. — While the most common protrusion of which the 
patient complains is some variety of hemorrhoids, it should be 
borrje in mind that there are several other conditions made mani- 
fest by protrusion at the anal orifice, among which may be men- 
tioned : prolapsus, polypi, hypertrophied papillae, and cancer. In 
questioning a patient regarding a protrusion, one should find out 
whether it appears with the stools or not; whether straining ef- 
forts are necessary to produce it, or whether it appears spon- 
taneously; whether it can be replaced, and if so, whether easily 
or not. One should inquire as to their number, whether they tend 
to remain outside of the sphincter, and whether or not their ap- 
pearance or replacement is accompanied by pain. 

Elevations. — Elevations found in the perianal region may be 
smooth and rounded, rough, hard, or soft and fluctuating, and are 
caused by external hemorrhoids, abscesses, lipomata, condylomata, 
or the external openings of fistulae. A rounded elevation occur- 
ring at one side of the anus, accompanied by pain of a throbbing 
character with some rise of temperature, will be found due to a 
marginal or ischiorectal abscess. A hard, rounded protuberance, 
occurring suddenly at the anal margin, accompanied by intense 
throbbing pain, will be found to be an acute thrombotic external 
hemorrhoid. A cluster of small rough elevations at the anal 
opening, usually posterior, is almost always condylomata. 

A small papular elevation anywhere in the perianal region from 
which a purulent discharge exudes is almost invariably the ex- 
ternal opening of a fistula. 

Discharge. — A history of discharge from the anus should al- 
ways suggest anoscopic and proctoscopic examination. Hemor- 
rhage has already been described above. While mucus may be 
caused by any irritation, acute or chronic, and accompanies prac- 
tically all forms of rectal disease, it may originate in some in- 
flammatory condition of the colon. The sigmoid should therefore 
always be explored when a mucous discharge is met with. Puru- 
lent discharge may come from colitis, but more often points to 



34 DisMSE^s 01^ the: rectum 

abscess, blind internal fistula, rectal ulceration, or malignant dis- 
ease. The odor which accompanies the discharge caused by the 
last-mentioned condition is almost diagnostic in itself. Many pa- 
tients who complain of pruritus, or local irritation of the anal 
region, will also complain of the moisture of the parts. It is well 
to bear in mind the possibility of disease of the Morgagnian 
crypts as the origin of this symptom. 

Constipation. — No case of constipation, particularly of the 
chronic variety, should ever be treated until a complete examina- 
tion has been made. So many cases of so-called constipation, 
which is purely a functional condition, are in reality due to 
mechanical causes. Coloptosis, floating kidney, prolapse, stric- 
ture, hypertrophied rectal valves, enlarged prostate, uterine dis- 
placements, adhesions, rectocele, perineal lacerations, fecal impac- 
tion, and many other diseased conditions often act in a purely 
mechanical way, causing obstipation, which can only be discovered 
after proper examination. 

Diarrhea. — Chronic diarrhea per se, or alternating with consti- 
pation, so frequently occurs as a symptom of carcinoma and ul- 
ceration, that these diseases should be excluded by examination 
before treatment is commenced. Persistent diarrhea, unaccom- 
panied by pain, occurring in an apparently healthy individual, is 
very suggestive of beginning malignant disease. 

Altered Stools. — Deviations in the normal appearance of the 
stools are often very suggestive, the large, hard stool of prolonged 
fecal retention giving a vastly different meaning than the narrow 
tape-like or pipe-stem stool of stricture. The color, consistency, 
and amount of the stool, as well as the appearance of blood, pus, 
or mucus with the movement, as has been noted above, are all 
of importance. 

Sacral Backache. — This is often the only subjective symptom 
of beginning malignant disease. It often accompanies internal 
hemorrhoids, prolapse, impaction, and various benign growths. 
It is a symptom which should always call for rectal examination. 
Many obstructive conditions of the sigmoid, as well as sigmoid- 
itis and fecal impaction, will often cause a sense of weight or 
constriction in the pelvis. When this occurs in females, and dis- 
eases of the uterus or adnexa are excluded by gynecological ex- 
amination, the sigmoidoscope should be used. 



SYMPTOMS 01^ RECTAL DISEASES 35 

Shooting Pains Down the Limbs. — These, particularly on the 
left side, may accompany all forms of rectal disease. Sciatica 
has been so perfectly simulated by rectal ulcer that diagnosticians 
have been repeatedly led astray. This is often the predominating 
symptom in lateral ulcer of the rectum. Ischiorectal abscess, 
particularly of the left fossa, frequently causes pains shooting 
down the limbs. 

Crampy, Painful, and Scanty Menstruation. — This, occurring 
in women who have perfectly normal genital organs, will be found 
upon rectal examination to be due in many cases to ulceration of 
the anterior rectal wall, fissure, or hemorrhoids. 

Urinary Disturbances. — Frequent and painful urination, pres- 
sure symptoms in the bladder, pain and burning at the vesical 
neck, enuresis : all may be due to a number of anal and rectal 
diseased conditions. Fissure and ulcer are the most frequent 
causes of bladder irritability. 

General Disturbances. — Loss of appetite, impaired digestion, 
nausea, headache, sallow complexion, and fever are frequently 
some of the symptoms of an autointoxication caused by some 
interference with the functions of the lower bowel, whose cause 
will be found upon rectal examination. 

Anemia. — Persons suffering from anemia should always be 
questioned as to the existence of rectal hemorrhage, as not in- 
frequently the loss of blood from internal hemorrhoids or ulcera- 
tion is so extensive as to account for the anemic condition. 

Restlessness in Children. — When children are restless at night 
and are continually picking at the nose or scratching the anus or 
genitals, an examination of the rectum will often disclose the 
presence of pinworms. 

Foreign Body. — The history of the swallowing of a foreign 
body, such as a pin or fishbone, followed in a few days by anal 
pain or tenesmus, should call for a rectal examination, and the 
offending cause of the trouble will be found not infrequently 
protruding from the mouth of one of the Morgagnian crypts. 



CHAPTER III. 

EXAMINATION OF THE PATIENT. 

ROOMS AND FURNITURE. 

The first and most important consideration is the location and 
arrangement of the examining-room. The ideal suite of offices 
should include, besides a reception room, a consultation room, an 
examining or operating-room, a toilet, and a resting or recovery 
room. The last two rooms should be situated at some dis- 
tance from the reception room and should be separated from the 
other rooms by walls which are soundproof. It is not a pleasant 
prospect for a patient in the reception room, nervously awaiting 
his or her turn, to overhear through flimsy plaster or glass parti- 
tions the recital of another's ailments, or the apprehensive ex- 
clamations of a high-strung or hysterical patient on the operating- 
table. Where a glass partition is all that separates the operating- 
room from the reception room, those in waiting are often treated 
to a shadowgraphic representation of the performance going on 
within. 

One who expects to do minor surgery and treatment work 
should equip himself properly for the same. A properly fitted- 
out and furnished operating-room should be provided, which could 
also serve as an examining-room as well. The room should be 
large enough so as not to be uncomfortably crowded with the 
furniture and paraphernalia necessary, and yet small enough to 
be compact. The floor should be of tile or granolithic material 
so as to be water-tight and easily cleansed. The walls should be 
tiled, enameled, or treated with some material that will stand 
scrubbing. All corners should be rounded off, and as little wood- 
work as possible should enter into its construction. 

The location of the suite will depend largely upon the location 
of the building itself, but where there is a choice, it will depend 
upon whether the strongest light is desired in the forenoon or 
afternoon. Heavy shades should be provided so that the operat- 
ing or examining-room may be darkened when artificial light is 
to be used. The w^alls and everything in the room, as far as 

36 



e:xAMINATION 01^ THE PATIE:nT 



37 



possible, should be white. White gives the patient an impression 
of cleanliness at once; and the slightest soiling is so conspicuous 
that they must be kept clean. 

The necessary furniture consists of a surgical table, or chair, 
which can be adjusted to various positions; an aseptic glass and 
metal instrument case ; glass-top instrument table ; revolving stool ; 





lyiHiiiiH 




Fig-. 5. A simple form of instrument sterilizer for office use. 




Fig. 6. A small instrument and dressing sterilizer. This is a very 
simple and popular form of steam sterilizer. The dressing for an office 
operation may be sterilized in the trays above the boiling instruments. 

Sterilizer (Figs. 5, 6), with stand; foot tub; with enameled bowls 
and dressing basins, pail, compressed-air tank, and plumbing, 
electric-light wiring, and other fixtures, according to the ideas of 
the individual. 

If it is not possible to have a toilet room adjoining the operat- 
ing-room, a commode should be added to the equipment. A re- 
tiring or recovery room is almost a necessity as well. 



38 DISEASES OF THE) RECTUM 

The author prefers an examining-table to a surgical chair. 
He believes that it is not more distasteful to the patient to 
get up on a table to be examined than it is to be seated in a chair 
and by the turn of a crank to be jerked or jarred, or flopped into 



Fig. 7. Columbus operating-table. This is a light but strong all- 
metal operating-table, particularly adapted for office work. It may 
be thrown into any position that either a surgical chair or table can be. 

position. Surgical chairs are cumbersome and always getting 
out of order, and are not to be compared with a nice, clean operat- 
ing-table of enameled iron which can be adjusted to any 
position required (Fig. 7). Hair-stuffed cushions covered with 



i:XAMINATlON OF THE) PATIENT 



39 



white rubber and not exceeding one inch in thickness are placed 
on top of the table. The cushions should be thick enough so as 
to counteract the hardness of the table, and yet not so thick that 
the patient's buttocks sink down into them. 

Plenty of clean white sheets should be always on hand, and the 
examiner will find it more comfortable and cleanly to wear a 
white linen or duck coat, such as are commonly worn by dentists. 
The author has found the electric headlight very useful where 
the interior of the rectum is to be examined, and believes it so 




Fig. 8. Electric magnifying headlight. This is a very simple, in- 
expensive, and very satisfactory electric headlight. It may be used 
either on the street current or vest-pocket battery. It is very light, 
compact, and can be so adjusted that the light is brought between the 
operator's eyes. There is a condensing lens which assists in focusing, 
thus greatly increasing its efficiency. 

far superior to the head mirror and lamp that he no longer uses 
the latter (Fig. 8). 

While it is extremely desirable to have such an equipment, as 
has been described above, a very satisfactory examination can be 
made on any sort of a table or bed with the aid of a good light. 
The technic which the author uses will be described, not because 
it will be found the best by all practitioners, but because he has 
found it the best and most satisfactory in his experience. 



EXAMINATION. 

The patient should first be asked into the consulting-room, and 
in order to put him at his ease, he should be allowed to tell his 



40 



DISEASES OF THE RECTUM 



HISTORY OP CASe No,... 

AGE 



Referred by Or. 



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Present history, ceko 





Treatment pai 



Fig. 9. A simple form of record card used by the author, size 
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Fig-. 10. Reverse side of the preceding on which the account with 
the patient can be kept. 



EXAMINATION Oi^ THE PATIENT 



41 



story of his ailments in his own way. As he mentions symptoms 
or salient points which are pertinent, they should be noted down 
for use in questioning him later. When he has finished, he should 
be questioned in a more systematic manner, and his history noted 
on a special blank or card kept for the purpose (Figs. 9, 10). 
The various symptoms brought out in this way will often suggest 
a tentative diagnosis, but as has been stated in the preceding 
chapter, nothing should be taken for granted and a complete rectal 




Fig. 11. External inspection. This drawing well illustrates the 
posture of both examiner and patient, and shows the extent to which 
the anus may be dilated by traction of the skin of the buttocks. 



examination insisted upon. The patient is then taken into the 
examining-room and prepared for the examination. All clothing, 
corsets, tight waistbands, or anything which constricts, or has a 
tendency to interfere with respiration, or to crowd the abdominal 
organs or intestines out of place, should be loosened or removed. 
The patient is then placed on the table in the left lateral or Sims' 
position and covered with sheets in such a manner that there is 
never any unnecessary exposure (Fig. 11). 



42 



DISEASES OF THE RECTUM 



With the patient so placed as to get good daylight, or by the 
aid of the headlight, the anus, perineum, buttocks, and the genital 
organs are carefully examined. Discolorations, protrusions, ele- 
vations, swellings, abrasions, cracks, skin eruptions, crusts, scars, 
discharge, or any other abnormal appearances of the parts should 
be carefully noted. 

Digital. — With the patient in the same position, digital exam- 
ination is next in order. It is well to have in readiness a bowl of 
some antiseptic solution, preferably one which will not attack 
steel instruments. The author has found a 1:10,000 solution of 




Fig. 12. Method of applying lubricant from collapsible tube to 
examining- finger protected with a rubber finger cot. 



mercuric iodid the most satisfactory. Its germicidal power is 
equal to that of the bichlorid in the strength of 1 :2,000. 

Finger cots should always be used in digital examination. The 
examining finger protected by the finger cot should always be 
well lubricated before an examination is attempted (Fig. 12). 
There are a number of excellent commercial lubricants on the 
market, such as Hartz's 'Xubra-Septol" and Van Horn's "K-Y," 
but sterile vaselin or oil will be found to answer the purpose al- 
most as well. The lubricant used by the author and which has 
given him perfect satisfaction is prepared as follows: 



EXAMINATION O^ THK PATIENT 



43 



IJ Hydrargyri oxycyanidi 0.246 

Glycerini 20. 

Tragacanthae 3. 

Aquae 100. 

Dispense in two-ounce collapsible lead tubes. 

The posture of the patient for digital examination is very im- 
portant. The old method of having a patient simply bend or 
lean over a chair or table, then inserting the index finger (Fig. 
13), is not nearly so satisfactory, comfortable, or thorough to 




Fig. 13. Incorrect method of digital examination. This metliod was 
deemed the only proper method of making a digital examination of the 
anus and rectum. Contrast this with the following illustration. 



either examiner or patient as the lateral or Sims' position (Fig. 
14). The patient in the Sims' position is relaxed and at ease, 
and the parts are presented in such a manner as to give the 
clearest view and produce the most satisfactory results. 

The wearing of a thin-rubber finger cot is done for several 
reasons. In the first place, it protects the w^earer from infection. 
It also prevents the soiling of the finger with fecal material, pus, 
or discharge with their disagreeable odors. It does not interfere 
with the sense of touch, which can be educated to extreme 



44 



DISEASES O^ THE RECTUM 



delicacy even with the cot. From the patient's standpoint it is 
much more desirable — the smooth rubber covering over the finger 
enabling it to enter much more easily than the unprotected finger, 
and there is no danger of irritating sensitive areas with the finger 
nail. If one wishes to make a digital examination, and a finger 
cot is not available, the nail of the examining finger should be 
trimmed close, and the crevices under and around it filled by 
scratching the surface of a bar of soap. The rest of the finger 




Fig. 14. Correct method of digital examination. With the patient 
in the lateral or Sims' position, the examiner standing behind the pa- 
tient, digital exploration of the anus and rectum can be accomplished 
with much more thoroughness, satisfaction, and comfort to both. 



nail should be covered with soapsuds, vaselin, or whatever lubri- 
cant is handy. After the examination, the lubricating material 
should be wiped from the finger with a dry cloth or absorbent 
cotton before washing the hands. 

The position of the patient and the examiner as well is shown 
in the accompanying illustration (Fig 14). The protected and 
lubricated finger, which is usually the index finger of the right 



EXAMINATION OF THE) PATIENT 45 

hand, is pressed against the anus with the flexor surface toward 
the posterior commissure, and the patient is asked to bear down. 
The finger is first entered pointing anteriorly until the sphincters 
have been passed, and then passed backward and upward in the 
posterior direction. As the finger enters, it should be gently 
turned from side to side sweeping over all the surfaces of the 
anal canal and lower rectum. Any change from the normal, soft, 
velvety feeling of this region — such as elevations, depressions. 




Fig-. 15. Vaginal eversion of the anus. This method is useful in 
examining- the anterior wall of the anus, and lower rectum in female 
patients, particularly those who have borne children and who have 
lax perineums. 

or indurations — should be carefully noted. The location of the 
feces is also important, particularly where symptoms of inter- 
ference with normal defecation are presented. It is therefore 
important not to give an enema before the first digital examina- 
tion. Unless one wishes to determine conditions high up in 
the rectum, or to make a rectoabdominal examination, one should 
not feel too high in searching for the source of painful rectal 
symptoms. Most of these diseased conditions will be found 
within the first two inches from the anal outlet. Often, in in- 



46 



DISEASES O^ THE RECTUM 



serting the finger, the various lesions are pushed up into the 
rectum, giving the impression that they are higher than they 
actually are. It is with the withdrawal of the finger, therefore, 
that more valuable information is often obtained than on its in- 
troduction. 

Where the sphincters are so sensitive or tightly contracted as 
to prevent digital examination being accomplished without great 
pain to the patient, dilatation of the sphincters by means of local 




Fig-. 16. Another method of everting the anal tissues for inspec- 
tion. — From Crossen: Diagnosis and Treatment of Diseases of Women. 

anesthesia should be employed. The technic of local anesthesia 
is fully described in Chapter XV, to which the reader is referred. 
In women much valuable information can be gained oftentimes 
by vaginorectal examination, which is accomplished either by the 
index finger in the rectum and the thumb in the vagina; or by 
using the index finger of the left hand in the vagina while the 
right is in the rectum. Often in women where the perineum is 
lax, the anus may be everted by downward and outward pressure 
of the index finger of the right hand in the vagina, while the 
anus is spread between the index finger and thumb of the left 
hand (Figs. 15, 16, 17). 



EXAMINATION OF THE PATIENT 



47 



The lithotomy position, while in most cases not nearly so satis- 
factory for complete ocular inspection of the external parts or 
the use of the anoscope — nor as comfortable for the patient — has 
its place in the examination of the patient suffering from ano- 
rectal diseases. If for some reason or other the patient is not 
comfortable in the lateral position, which will occasionally be the 
case in those who suffer from rheumatism or some other joint 



^ 





Fig-. 17. Indicating the amount of possible aversion of anal tissues 
where the pelvic floor is lax, as in multiparse. — Dudley: Practice of 
Gynecology. 

affection; or on account of an unusual amount of adipose tissue 
the patient's buttocks cannot be well separated in the lateral posi- 
tion, the lithotomy position will be found much more satisfactory. 
The patient is asked to lie flat upon the table after the clothing 
has been removed, and a sheet thrown over him. The knees are 
flexed upon the thighs, the thighs upon the abdomen, and the 
patient's buttocks pulled well down to the edge of the table. The 



48 



DISEASES OE THE RECTUM 



legs are kept in this position either by an assistant or by the use 
of a Kelly leg holder or Clover's crutch, or by the stirrups or leg 
holders which accompany the surgical table used by the author, 
known as the Columbus table. In this position the perineal space 
and the perianal region can be inspected and palpated, and in the 
case of a female patient, examination of the genital organs carried 
out at the same time. In this position also the condition of the 
prostate and seminal vesicles of the male can be made out, and 
oftentimes the extent and direction of a fistulous tract determined 




Fig-. 18. Method of examining the coccyx with one hand. This 
may also be done with one hand over the region of the coccyx, pos- 
terior to and above the anus, and the index finger of the other inside 
of the rectum. — Hirst: Diseases of Women. 

more satisfactorily than in the lateral position. The condition 
of the coccyx can be determined with the patient in the lithotomy 
position by inserting one finger into the rectum with the other 
hand over the region of the coccyx, or by inserting the fore- 
finger into the rectum with the thumb of the same hand over 
the location of the coccyx on the outside (Fig. 18). 

With the patient in the lithotomy position, bimanual abdomino- 
vaginal, and abdominorectal examinations are accomplished ( Figs. 
19-22). It is a good, safe plan to include both of these methods 



EXAMINATION OF THE PATIENT 



49 



in the routine examination of every patient, because very fre- 
quently unsuspected or beginning diseased conditions in the pelvis 
and abdomen are discovered before they have given rise to sub- 
jective symptoms. In any case presenting the symptoms of 
sacral backache, weight in the pelvis, the passage of blood or 
pus with the stool, or diarrhea, abdominorectal palpation, with 
the right index finger inserted as high as possible in the rectum, 
and the left hand over the right and left iliac fossae and above the 
pubes, is imperative. 




Fig. 19. Posture and method of making rectoabdominal bimanual 
examination. 



The squatting position (Fig. 23), or the position assumed by 
the aboriginal races in defecation, is oftentimes of great value in 
the diagnosis of those conditions made manifest by protrusions 
from the anal orifice. The patient is asked to remove his cloth- 
ing and to squat as if he wished to defecate. It is best to place 
a shallow basin or receptacle underneath him lest, during his 
straining efiforts, feces, pus, blood, or discharge may escape. The 
patient is then asked to bear down or strain; when in this posi- 
tion, prolapsing internal hemorrhoids, polypi, or prolapse of the 



50 



DISEASES 0^ THE RECTUM 



rectum or anus will be brought into view in a very satisfactory 
manner. 

Internal Inspection. — Before proceeding to internal inspection, 
the rectum should be emptied by means of an enema of soapsuds 




Fig". 20. Method of rectoabdominal palpation. The position of both 
hands in relation to the uterus and vagina is well shown. — Montgomery: 
Practical Gynecology. 




Fig". 
Ashton: 



21. Palpation of rectum through posterior vaginal wall.- 
Practice of Gynecology, 



and water. If one's office equipment does not include an irrigator, 
a two-quart fountain syringe will answer very nicely. Another 
very simple method is to use a three or four-ounce, soft-tipped, 
all-rubber bulb syringe, known as the ear-and-ulcer syringe (Fig. 



EXAMINATION 01^ THE PATlKNT 



51 



24). With the patient in the lateral or Sims' position a pint or 
more of solution can be gently injected, and the rectum cleansed 
in a very satisfactory manner — the patient being allowed to rise 
and go to the toilet to expel it. 

Internal inspection of the anus, rectum, and sigmoid is best 




Fig. 22. Ischiorectal abscess. This illustration, besides showing- 
the point of swelling and fluctuation of the abscess, illustrates the 
method of bimanual palpation in the examination and diagnosis of the 
condition. At the posterior commissure of the anus will be seen a small 
external hemorrhoid as well. 



accomplished with the patient in the knee-shoulder position. The 
patient, who has been lying in the Sims' position, is asked to 
kneel on the table and to maintain the kneeling position while 
the examiner brings the left shoulder down to the table flush 
with the knees. The patient should not be allowed to rest on 
the elbows as the trunk must present enough of an inclined plane 



52 



diskase:s of th^ rectum 




Fig-. 23. Squatting- position. This position shows the natural pos- 
ture for defecation, and is useful in extruding- prolapsing conditions. 




Fig. 24. Three-ounce, all-rubber bulb syringe. Useful in irrigating, 
and in giving enemata when an ordinary irrigator is not available. 



EXAMINATION OF THE) PATIENT 



53 




Fig. 25. Knee-elbow position. This position is often mistakenly 
employed in proctoscopy, and should not be confused with the knee- 
shoulder position, as depicted in the following illustration. 




Fig. 2G. Knee-shoulder position. This is the correct posture for 
proctoscopic examination. By comparing this with the preceding one, 
it will be seen that in the knee-shoulder position much more of an 
inclined plane is produced. Note the direction in which the proctoscope 
is introduced. 



54 DISEASES O^ THE RHCTUM 

to allow atmospheric dilatation of the rectum, when the examining 
instruments are inserted, and allow the other abdominal organs 
to fall away from the rectum. The accompanying illustrations 




Fig. 27. Author's anoscope with oblique opening and slantinj 
obturator. 




Fig-. 28. Author's adjustable fenestrated anoscope. This instru- 
ment is provided with a closed extremity; has a fenestrum 1% inches 
long by V2 inch wide; can be revolved so that the fenestrum can be 
placed at any angle in relation to the handle; and on account of the 
peculiar shape of the ferrule at the proximal end of the fenestrum, is 
self-retaining. 

clearly show the difference between the correct and incorrect 
postures (Figs. 25, 26). 

Oftentimes the internal opening of a fistula can be determined 



EXAMINATION OF THE PATlKNT 55 

by the injection through its external opening of a solution of 25 
per cent peroxid of hydrogen. Upon examining through the 
proctoscope, while injecting, the internal opening can be easily 
located by the appearance of the bubbling peroxid solution. Solu- 
tions of methylene blue or milk of magnesia or bismuth paste 
can also be used in like manner for a similar purpose. The in- 
jection of fistulous tracts with bismuth paste, as advocated by 
Emil Beck (Chap. IX), is of the greatest value in the produc- 
tion of stereoscopic radiographs. This is the refinement of diag- 



Fig. 29. Silver probe. This type of probe, equipped with a proper 
handle and made of pure, annealed silver, is adapted for use in rectal 
examination. It is made in many sizes. 




Fig. 30. Long alligator forceps. These are made in different sizes, 
ranging from 9 to 14 inches in length, and are very useful in procto- 
scopic and sigmoidoscopic examination. 

nostic technic in the location of all of the ramifications of an 
anal fistula. 

For internal inspection of the anal canal, the lateral Sims' 
position is sufficient. 

Anoscopy. — The instruments required for inspection of the 
anal canal, or anoscopy, are: a cylindrical anoscope, whose in- 
ternal opening is oblique, and containing an obturator tapering 
to a blunt round extremity (Fig. 27) ; the tapering, adjustable 
fenestrated anoscope with closed extremity (Fig. 28) ; a fine flex- 
ible probe (Fig. 29), made of pure silver; and a pair of dressing 



56 DISEASES OE THE RECTUM 

forceps (Fig. 30). An ordinary Kelly anoscope (Fig. 31) is 
also oftentimes very useful. 

Bearing in mind from the digital examination the location of 
the lesions in the anal canal, the fenestrated anoscope, well 
lubricated, with the opening turned so as to be opposite the lesion 
when entered, is pressed against the anus and gently inserted 
while the patient is bearing down against it (Fig. 32). If an 
opening is detected, this may be explored with the soft-silver 
probe, which may be bent easily at any angle, care being taken 
to use no force and to handle it with extreme gentleness ana 
delicacy. In some cases, the instrument with the oblique opening 
is used in preference, its opening giving nearly twice the field 
of the ordinary circular opening of the Kelly instrument. The 
Kelly anoscope, however, is useful in exposing conditions which 




Fig. 31. KeUy anoscope. Useful in prolapsing- conditions. 

prolapse — the patient being asked to strain and bear down while 
the instrument is being withdrawn. 

By doing so, prolapsing hemorrhoids, prolapse of the anus or 
rectum, polypi, or papillae are brought out into view. If the view 
is obscured, at any time, a bit of cotton should be taken up with 
the dressing forceps to cleanse the parts. 

The knee-shoulder position is by far the most satisfactory in 
the author's experience for examination of the rectal cavity and 
most of the sigmoid. Not only does the atmospheric pressure 
balloon out the rectum to its fullest capacity, but this position 
also removes the pressure of other abdominal organs from the 
rectum by allowing them to fall away. 

Proctoscopy. — The only instruments required for proctoscopy 



EXAMINATION OF THE PATIENT 



57 



or ocular inspection of the rectal cavity are : a cylindrical procto- 
scope, from four to six inches in length and from three quarters 
to seven eighths of an inch in diameter, and a pair of long alligator 
forceps. In an emergency, a very fair inspection of the rectal 
cavity may be had without any instruments whatever. The 
technic of proctoscopy without instruments is as follows: 

With the patient in the knee-shoulder position, the index finger 




Fig. 32. Posture and method of usinj 
anoscope, for examining the anal canal. 



the author's fenestrated 



of the right hand, protected by a finger cot, and well lubricated, 
is gently inserted, and the sphincter massaged; then the inde* 
finger of the left hand, similarly protected and lubricated, is in- 
troduced back to back with the finger in the rectum. The in- 
troduction of the second finger should be done slowly and gently 
and with a massage-like motion. When it has been introduced 
to an equal depth with its fellow, that is, up to the second joini 



58 



disease:s o^ the; rectum 



of the finger, the fingers should be gently separated. The at- 
mospheric air then rushes in with an audible hiss, and the rec- 
tum balloons out so that it can be examined with the aid of the 
electric headlight or reflected light from the head mirror. 

With this method, however, one cannot see behind the rectal 
valves or folds of Houston, and it is only of value where a suit- 
able examining instrument is not at hand and the lowermost 
portion only of the rectal cavity is to be explored. 

The technic of proctoscopy is as follows : 

With a proctoscope whose outside diameter does not exceed the 




Fig. 33. Author's modification of the Martin proctoscope, provided 
with a metal obturator with conical extremity, which contains an air 
vent running through its entire length. It is % inch in diameter 
and 6 inches long:. i 

diameter of the operator's index finger, all parts of the rectal 
cavity can be successfully explored, and its introduction causes 
no more pain or discomfort than digital examination. The in- 
strument used by the author is a modification of that devised by 
T. C. Martin (Fig. 33). It is five and one-half inches long from 
the edge of the flange to the tip of the obturator. Its outside 
diameter is three quarters of an inch. It is provided with an 
obturator made of metal, with a conical extremity which fits it 
very snugly. The obturator is channeled so as to allow the in- 
gress of air during its introduction. With the patient in the 
knee-shoulder position, the well-lubricated proctoscope is pressed 



EXAMINATION OF THE) PATIENT 



59 



against the anus, pointing in the direction of the patient's um- 
bilicus, and the patient asked to bear down, as in the act of de- 
fecation. While he is doing so, the proctoscope is inserted gently, 
first downward and forward, until the anal canal has been passed ; 
when it is tilted upward and backward and the rectal cavity is 
entered without difficulty. By asking the patient to bear down 
during the introduction of the instrument, the- patient forces his 
anus down over the proctoscope, as it were, and introduction is 
accomplished with much ease. Holding the proctoscope in the 




Fig. 34. 
the patient 



Exaggerated lithotomy position. Illustrating posture of 
.nd technic of introduction of the sigmoidoscope. 



left hand, the obturator is withdrawn with the right. Inspection 
of the entire rectal cavity can then be accomplished with as much 
ease and completeness as the examination of the nose or throat. 
The proctoscope should always be entered to its fullest length 
before the obturator is withdrawn. 

After examining the uppermost part of the rectum, and 
noting the appearance and condition of the rectosigmoidal 
juncture, it is slowly withdrawn, the examiner in the mean- 
while noting the condition of the lining membrane of the rec- 
tum, the rectal valves, and anal canal until the instrument is 



60 DISEASES OF THE RECTUM 

completely withdrawn. If, upon the withdrawal of the obtu- 
rator, the opening of the protoscope seems closed by a wall of 
rectal mucous membrane, by manipulating the instrument so 
that its inner extremity is moved to one side or the other, the 
obstruction will often be found to be one of the rectal valves, 
or folds of Houston.; and on pushing this to one side with the 




Fig-. 35. KeUy sigmoidoscope. This is made in sizes varying from 
to 14 inches in length. 




Fig. 36. Sigmoidoscope provided with the author's tilting obturator. 
The tilting obturator is of value in the insertion of the sigmoidoscope, 
allowing it to round the sacral curve with greater facility. 

instrument, a new field is exposed to view. With the procto- 
scope in position, the size, density, and thickness of the rectal 
valves can be noted by means of a probe or applicator bent at 
a right angle; ulcerations of the rectal wall, their extent and 
severity, noted; the condition of the circulation of the rectum; 



EXAMINATION OF THE PATIENT 



61 



the presence of polypi — in fact, any deviation from the normal, 
smooth, pinkish-red appearance of the mucous membrane of 
the normal rectum easily made out by this method of examina- 
tion. The condition of the upper surfaces of the rectal valves 
and the inner aspect of the anal canal can be accurately deter- 
mined by the use of a small laryngoscopic mirror mounted on 




Inverted or Hanes position. 



a long flexible handle. While the proctoscope is in position, 
local applications to diseased areas, sprays, insufflations, and 
other therapeutic measures, when indicated, may be carried on 
under the direct guidance of the eye. The alligator forceps 
are useful for swabbing out the rectum and obtaining tissue for 
microscopical examination. 



62 



DISE)ASKS 0^ the: RKCTUM 



Sigmoidoscopy. — The exaggerated lithotomy position (Fig. 34), 
also sometimes known as the genitourinary position, is very use- 
ful when it is necessary to examine the sigmoid flexure. This 
position is secured by putting the patient in the lithotomy 
position, as above described, and then slowly lowering the head 
of the table so as to leave the buttocks somewhat higher than 
the patient's shoulders. This puts the patient in a sort of 




Fig. 38. Imperforate anus in one-year-old child. Injected with 
bismuth throug-h inguinal anus, which was made when child was forty- 
eight hours old. Coil of wire indicates normal anal site. 

semi-Trendelenburg position with the thighs and knees flexed. 
In this position it will be found comparatively easy to introduce 
the sigmoidoscope and secure atmospheric dilatation of the 
sigmoid flexure. 

The instruments necessary for the ocular inspection of the 
sigmoid flexure, or sigmoidoscopy, are sigmoidoscopes varying in 



EXAMINATION 01? THE PATIENT 



63 



length from nine to fourteen inches, and from five-eighths to an 
inch in circumference, and the long alligator forceps. The in- 
strument devised by Kelly (Fig. 35) is very serviceable, but its 
introduction has been made much easier by the use of an obtu- 




Fig-. 39. Atresia ani vaginalis (complete). Photograph of author's 
case. This illustrates a case of complete absence of the anus with the 
rectum emptying itself through the vagina. The patient was 25 years 
old and did not know until shortly before consulting the author that 
she was different from other people. She had partial control of her 
fecal movements by an overdevelopment of her sphincter vaginae. At 
the normal location of the anus was found a rudimentary external 
sphincter. The case was operated on by the author, the vaginal 
opening closed, and the rectum brought down to the normal anal site, 
with the result that the patient has an apparently normal anus with 
good control. The above photograph well shows the septum separating 
the rectal opening' into the vagina from the upper vaginal canal. 

rator whose projecting extremity tilts so as to allow of easier 
introduction in rounding the curve of the sacrum. Tuttle has 
devised such an instrument, as has also the author (Fig. 36). 
The only instrument required is a long alligator forceps for use 



64 



dise:ases o? the rectum 



in swabbing out the sigmoid cavity and for the purpose of re- 
moving tissue for miscroscopical examination. Sigmoidoscopy 
may be accompHshed with the patient in the knee-shoulder posi- 
tion, but much more satisfactory results are obtained from the 




Fig, 40. Atrtesia ani vaginalis (incomplete). This photograph,, taken 
from one of the author's cases, differs from the preceding in that, 
while the patient passed her stools through the vaginal opening, the 
anus was not entirely occluded, there being a small anovaginal fistula. 
This patient was 23 years old, and had a remarkably well-developed 
sphincter vaginae, and was able to control well her fecal movements 
through the vulvar orifice. This case was likewise operated on, and 
the rectum restored to its normal position with a good functional and 
cosmetic result. The external sphincter muscle was more fully de- 
veloped in this case than in the preceding one, and control followed 
much more rapidly. 



employment of the exaggerated lithotomy position. Dr. Gran- 
ville S. Hanes, of Louisville, Ky., has introduced the inverted 
position for sigmoidoscopy (Fig. 37). 

Examination for Congenital Defect or Malformation. — 



EXAMINATION OE THE PATIENT 65 

Before leaving the subject of examination of the patient, the 
author would advise his readers to carefully examine every 
patient to make sure that there is not present some congenital 
defect or malformation of the anus or rectum (Fig. 38). Every 
infant at birth should be examined by the attending obstetrician to 
make sure that the anorectal canal is patent, as imperforate anus, 
while said to occur but once in 10,000 cases, seems to the author, in 
his own experience and that of his professional friends with 
whom he has consulted, to have occurred far more frequently. 
If imperforate anus is not recognized, the child will die in either 
a few hours or days if the condition is not remedied, and even 
then, the operation is attended with a very high mortality ; or 
nature will occasionally form a new outlet for the escape of the 
feces. In girls this happens more frequently through the vagina, 
and in male infants through the scrotum, bladder, or urethra. 
Three cases have come under the author's notice in which girls 
were allowed to grow to womanhood with congenital defects so 
serious as to preclude the possibility of marriage until remedied. 
In two (Fig. 39), there was a complete absence of an anal orifice, 
and in the other (Fig. 40), an aperture about one fifth of the 
normal size. In all of the cases, defecation took place through 
the false opening into the vagina. 



CHAPTER IV. 
CONSTIPATION AND OBSTIPATION. 

Constipation is, and always will be, one of the most common 
conditions affecting the human race. Some writer has put it 
that "every other man and every woman is constipated." While 
this statement may be somewhat of an exaggeration, it is a fact, 
nevertheless, that constipation, or at least some interference with 
normal defecation, is the most common and most prevalent 
affection of the human race. 

No patient who comes into the office of the average physician 
is turned away more quickly with a single prescription for some 
drug or combination of drugs than the constipated individual. 
The patient whose condition is one whose diagnosis cannot be 
made without a careful inquiry into his history, habits, and mode 
of living; and without a most careful and complete local exam- 
ination of the organs most involved, is the one, above all others, 
who is suffering from infrequent, irregular, or incomplete excre- 
tions from his alimentary tract, and loosely classified as the 
constipated patient. 

Because of thoughtless, careless, or unscientific medication by 
practitioners who are either ''too busy" to give the patient the 
proper time for a careful consideration of his case, or because of 
a lack of knowledge on the part of the practitioner who has been 
graduated from college without any training in the methods of 
rectal and sigmoidal examination, or the treatment of diseases of 
the intestinal tract, particularly of the large bowel, the majority 
of patients suffering from so-called constipation have been driven 
to self -medication by means of proprietary cathartic preparations, 
and have been lost to the legitimate practitioner of medicine. Many 
a patient has become a slave to cathartics and enemata, and has 
exhausted the laxative properties of one preparation after another, 
because of the fact that when he did consult his physician he 
was given a prescription for "A. S. & B. pills," or "a dose of 
salts" every morning, and that was all there was to his treatment. 

Constipation may be defined as the voiding of insufficient 

66 



CONSTIPATION AND OBSTIPATION 67 

amounts or the abnormally prolonged retention of fecal material 
in the intestinal canal. Constipation, in contradistinction to obsti- 
pation, is due to purely functional diseases or conditions of some 
portion of the intestinal tract. Obstipation, on the other hand, is 
a condition in which there is a sufficient quantity of fecal material, 
and a normal functional activity ; but in which some deformity, 
growth, flexion, constricture, or foreign body in the intestinal 
canal offers a mechanical obstruction to the passage of the fecal 
current. These two conditions are so frequently confounded in 
the mind of the average practitioner that the distinction must be 
always borne in mind ; for the treatment of these conditions, while 
they may present similar symptoms, is entirely different. 

Constipation is really but a relative condition. One individual 
may have two or three passages daily and still be constipated, 
while another individual may have but one passage a week and 
this condition be normal for him. 

Constipation in itself is not a disease but merely a symptom 
of a great many diseased conditions, but is so often the only 
apparent symptom of which the patient complains, that its dis- 
cussion as a separate disease entity is deemed advisable. 

Obstipation is caused by such mechanical conditions as malfor- 
mations of the intestinal canal, stricture, adhesions, pressure from, 
the pregnant uterus and the various abdominal tumors, angulation, 
enteroptosis, stenosis of the iliocecal valve, fecal impaction, the 
presence of foreign bodies, hypertrophied rectal valves, prolapse 
of the rectum or sigmoid, large hemorrhoids, enlarged prostate, 
lacerated perineum, and hypertrophied or contracted sphincters. 

Chronic constipation is a condition which affects a large pro- 
portion of all the patients treated by every practitioner of medicine. 
It is a condition which is brought about by our modern, so-called 
''strenuous life." We find it in the infant and in the nonagener- 
ian. It is due to a great many factors, and in order that one may 
understand it more fully, the author will review some points in 
the physiology of peristalsis and defecation. 

PHYSIOLOGY OF DEFECATION. 

Up to the last moment at which the fecal mass is expelled from 
the anus, the ingested materials are carried through the intestinal 
tract by what is known as peristaltic action. 



68 DISEASE'S OF THE RECTUM 

Recent studies of intestinal peristalsis, by means of repeated 
radiographs made of the large and small intestines after the in- 
gestion of a bismuth meal, have given us some new light on the 
normal movements of the intestines. We now know that it takes the 
contents of the small bowel four hours to travel from the pylorus 
to the cecum, the distance traversed being twenty-two and one-half 
feet in the average case. From the ileocecal valve to the rectosig- 
moidal juncture the rate of progress is much slower, the average 
time being from fourteen to twenty hours. It will be noted, 
therefore, that the waste products of ingested food should nor- 
mally be expelled approximately twenty- four hours after the meal. 
Retention longer than that period would make the individual 
either a constipated or an obstipated patient, depending on the 
cause of this retention. 

After the food has entered the stomach and the albuminoids are 
converted into peptones, it passes through the pylorus into the 
small intestine. As the stomach contents pass through the pyloric 
valve, they are acid. The secretions in the small bowel — the bile 
and the pancreatic juice — being alkaline when the acid contents are 
poured into the small intestine, coming in contact with the alka- 
line intestinal secretions, a stimulation, or irritation, is caused, 
which produces a wave of muscular contraction, or peristalsis, 
called segmentation. 

At the same time that the chemical reaction of the stomach con- 
tents on those of the intestine is going on, certain gases are created. 
These gases serve to distend and increase the caliber of the bowel, 
and by this distention still further stimulate muscular contractions. 
These gases are not abnormal but serve a most useful purpose. 
It is when they are in too great quantities, and too severe per- 
istalsis and consequently too great distention of the intestinal 
canal are produced, that they are harmful. They then cause 
atony or paralysis of the circular muscle-fibers and loss of mus- 
cular tone. These gases are largely reabsorbed by the blood- 
vessels or discharged from the anus. If these gases in their 
downward passage meet any obstruction, they are forced back- 
ward into the stomach and may be discharged in this direction. 

Another very important source of stimulation to the coats of 
the bowel is the harsh, indigestible particles of food which are 
not acted upon by the digestive secretions. These also irritate 



CONSTIPATION AND OBSTIPATION 69 

the mucous lining of the bowel, and stimulate the contraction of 
the circular muscular fibers of the small intestine. Of no small 
importance is the stimulus caused by the to-and-fro movement 
imparted to the bowel by the movements of respiration. The up- 
ward and downward excursions of the diaphragm impart to the 
small bowel in particular, but also to the transverse colon, a move- 
ment which stirs up and churns, as it were, the intestinal contents. 
The respiratory movements change the position of the bowel, and 
help to keep the intestinal contents on the move. It can be easily 
seen, therefore, how any article of clothing, or posture assumed, 
or certain occupations which restrict and prevent the full expan- 
sion of the chest will interfere with the intestinal functions and 
assist in causing constipation. 

The intestinal contents are fluid until they reach the iliocecal 
valve. In the cecum they become less fluid, and having to travel 
against the force of gravity, their movement in the large bowel 
is checked. Remaining, as they do, in this portion of the bowel 
for fourteen to twenty hours, the fluid constituents are gradually 
absorbed, and the nearer to the sigmoid the feces, the more solid 
they become. The mucous membrane of the colon is thicker and 
not so sensitive as that of the small intestine and requires more 
stimulation ; consequently the stools are more solid in this por- 
tion of the bowel. If, however, an excessive amount of vege- 
table fiber and indigestible material is present, the colon tends to 
become overstimulated, overdistended, and atonic ; the fecal mass 
moves very slowly, and chronic constipation, and sometimes fecal 
impaction, results. The fecal material, when it reaches the sig- 
moid, rests until ready to be passed out through the rectum and 
anus, as a fecal movement. 

This reabsorption of the toxins mentioned above, which toxins 
are in solution, causes an autotoxemia, which in itself is respon- 
sible for the symptoms improperly called ''bilious." Among 
these symptoms may be enumerated dizziness, vertigo, headache, 
loss of appetite, foul breath, mental sluggishness, a lack of ambi- 
tion, nausea, and in some cases periodic attacks of vomiting, and 
a general feeling of fatigue and listlessness. The liver is more 
often upset by the absorption of toxic material from the large 
bowel through the portal circulation than are the so-called syn- 
drome of biliousness and so-called torpid liver caused by consti- 



70 DISEASES O]? THE RECTUM 

pation. Bile is not nearly so important a factor in normal peri- 
stalsis and defecation as was formerly thought. Its presence 
does not stimulate peristalsis in the small intestine to any appreci- 
able degree. In fact, its presence is not necessary for the pro- 
duction of peristalsis or defecation. It is merely the excretion 
of the liver containing the waste products remaining after the 
liver's performance of its more important functions of detoxify- 
ing poisons that enter the body by way of the gastrointestinal 
tract; to store up some of the excess of fat taken as food, and 
to release it when the external supply becomes deficient ; to store 
up glycogen and to convert it into glucose and liberate it as 
required by the system; to assist in the metabolism of the pro- 
teins to the extent at least of forming urea or ammonia com- 
pounds, and other minor functions. The poor old liver has trouble 
of its own without being blamed for all of the cases of constipa- 
tion in the world. 

The argument advanced by some, that the administration of a 
laxative, which, by increasing the flow of bile and by unloading 
the liver, empties the bowel, thereby relieving the symptoms of 
autointoxication, is conclusive proof that the liver is at fault in 
the matter, loses its force entirely when we recall that many cases 
of autotoxemia are relieved by the mechanical cleansing action 
of an enema or colon flush. This, of course, acts without the 
assistance of the so-called natural purgative bile. The errone- 
ously named "liver pill" accomplishes the same result by its pur- 
gative action, without regard to the fact of its having a chola- 
gogic action or not. The fact that bile is not essential to normal 
defecation is illustrated very nicely in the normal intestinal per- 
istalsis and defecation, taking place in patients sufifering from a 
permanent biliary fistula, and who have no bile in the intestinal 
tract at all. 

ETIOLOGIC FACTORS. 

It can readily be seen that anything which interferes with the 
proper development and exercise of the intestinal muscular layers 
will interfere with the proper movement of the intestinal con- 
tents and with their expulsion at the proper time. In the first 
place, enough fluids must be taken daily into the system to keep 
the intestinal contents in solution and to properly supply the 



CONSTIPATION AND OBSTIPATION 71 

various organs of the body. On the other hand, people who do 
not drink sufficient water suffer from constipation because of the 
reabsorption of fluids from the intestinal tract and resulting hard 
and dry stools. People who drink great quantities of water with 
their meals drown their stomach contents ; undigested particles 
of food are sent through the pylorus with large quantities of 
greatly diluted gastric juice ; the feeble acid reaction of this 
mixture does not cause the proper reaction with the alkaline in- 
testinal contents ; the proper amount of gases is not evolved, and 
quantities of intensely irritating food particles are passed down 
the small bowel. This is another cause of loss of tone. 

It is a well-known fact that carnivorous animals are constipated, 
while the herbivorous animals have full and frequent bowel 
movements. Realizing this fact, it therefore behooves us to see 
that a sufficient quantity of vegetable material, which will leave 
undigested fiber in sufficient quantities to produce stimulation of 
the muscular fibers of the bowel, such as corn, cabbage, celery, 
carrots, beet tops, lettuce, spinach, watercress, endive, kale, and 
other green vegetables, as well as seed vegetables and fruits, is 
incorporated in our daily regimen. The dietary should also contain 
a sufficient quantity of mineral salts, particularly sodium chlorid, 
which are natural laxatives. It should also contain sweets within 
reasonable limits, because of the gas development which they 
cause, bearing in mind the fact that carbon dioxid gas is one of 
our best laxatives. Above all, the food must not be concentrated ; 
it must give sufficient bulk to the stool so that it will properly fill 
and distend the bowel, give it work to do, and thereby produce 
the proper stimulation to contraction, which is distention. The 
value of oatmeal, whole wheat bread, and bran lies in the quantity 
of cellulose in the husk, which is a very important element in the 
stimulation of the mucous lining of the bowel. People who fre- 
quent the quick-lunch counter and who devour a full meal in ten 
minutes do not properly masticate their food, thereby causing in- 
complete stimuli to peristalsis, and consequently improper stools. 

Outside of dietetic error, the most common cause of constipa- 
tion is neglect. The school child receives the call of nature, the 
fecal mass is ready to be extruded, he is receiving powerful 
stimuli for the dilatation of the sphincters and the expulsion of 
his bowel contents ; but in our modern schools the lesson hour is 



72 diskase:s o^ the: rectum 

more important than the functions of nature! The child is not 
allowed to go -and relieve himself. He restrains nature's efforts, 
and the desire passes away. The continuance of this perform- 
ance day after day soon makes the child chronically constipated. 

While peristalsis is involuntary, in the vast majority of people 
the voluntary control over the sphincter is normally sufficient to 
withstand peristalsis. The strong expulsive efforts soon weaken 
when opposed and retarded by a tightly contracted sphincter, and 
shortly the constipated habit is induced. The young girl in 
society is taken with a desire to move her bowels ; and either be- 
cause the time is not convenient and she restrains nature's efforts, 
or because she may be willing to satisfy nature's desire, but the 
location of the toilet room is such that the nature of her errand 
would be evident to others whom she would be obliged to pass, 
and false modesty prevents her from allowing her friends to see 
her go even in the direction of a retiring-room, she restrains 
nature's efforts, the desire soon passes away, and she thus be- 
comes constipated. 

A very important provision in architecture of homes and other 
buildings should be the placing of toilet rooms in such incon- 
spicuous places that a person may reach the same without being 
subject to the gaze of others, and the making of the seats of such 
a height as to force the user to assume a squatting posture. 

The business man, the professional man, the traveler — yes, even 
the physician — all refuse to obey nature's call, because they are 
too busy or the time does not happen to be convenient ; and thus, 
because we cannot find time to move our bowels when they 
should be relieved, we have become a constipated nation. As a 
result, the newspapers, magazines, and signboards flaunt the ad- 
vertisements of cathartic syrups, cathartic pills, candy cathartics, 
and aperient waters in our faces wherever we may turn. This 
neglect and indifference, in our humble opinion, is the most im- 
portant cause of constipation. 

Another contributing cause to the voluntary repression of de- 
fecation is the fact that schools, office buildings, and institutions 
generally, which are occupied or inhabited by a large number of 
people, do not have anywhere near enough toilet rooms for the 
number of inmates. Where one has to wait long for his turn, 
the desire for defecation is soon lost. 



CONSTIPATION AND OBSTIPATION 73 

The shape of the closet seat and its height from the floor are 
of importance in the production of a good stool. The seat 
should be so constructed that the person using it has to assume 
the squatting position, instead of the ordinary sitting. The 
buttocks should be well separated so as to allow the free excur- 
sion of the muscles, which go to make up the pelvic floor, down- 
ward and upward, and the full action of all the other muscles in- 
volved in defecation brought into play. People leading sedentary 
lives, who do not get sufficient exercise, are, of course, consti- 
pated. Exercise is one of the important factors in keeping all 
of the bodily functions normal. There are many other causes 
which may contribute to the production of constipation in in- 
dividual cases, but those mentioned are the most common, and 
by far the most important. 

When the bowel has become atonic, remedies to restore its 
tone must be employed. In the treatment of acute constipation, 
cathartic drugs, suppositories, enemata, all have their proper 
place, but the victim of chronic constipation should no more be 
made a victim of the drug habit than the patient suffering from 
chronic appendicitis. Instead of causing irritating, irregular, 
erratic, and violent peristaltic movements at certain times during 
the day, and instead of changing from one cathartic to another 
and increasing the dosage — instead of taking away the natural 
physiologic work of the bowel by flushing enemata — we should 
strive to bring that bowel back to its normal tone by imitating 
nature's method. The only place for a cathartic in the treatment 
of chronic constipation is the first dose at the beginning of the 
treatment. 

DIAGNOSIS. 

When a patient consults you, complaining of infrequent or in- 
sufficient bowel movements, the first thing to do is to make a 
diagnosis between constipation and obstipation. The patient 
should be examined carefully ; and here the writer wishes to state 
that, if the general practitioner of medicine would make it a 
routine practice to examine the anus, rectum, and sigmoid of 
every patient who presents symptoms directed toward these 
organs, he would meet with much greater success ; and he would 



74 DISI^AS^S 01? THE RECTUM 

discover that the treatment of anorectal diseases is not nearly so 
distasteful as he had heretofore thought. 

The writer holds that no patient, presenting the symptoms of 
interference with the regularity or quantity of his bowel move- 
ments, should have any treatment, without that patient being sub- 
jected to a complete digital, anoscopic, proctoscopic, and often 
sigmoidoscopic examination, in order to make a definite diagnosis. 
The patient suffering from the symptoms of constipation is just 
as much entitled to a proctologic examination as the one suffering 
from a cough is to the inspection, auscultation, and percussion of 
the chest. Every patient, male or female, should receive a bi- 
manual rectoabdominal examination, and the female patient the 
vaginal examination in addition. In the male patient the condi- 
tion of the bladder and prostate should be carefully noted. 

In examining with the proctoscope, it is advisable always to 
place the patient in the knee-shoulder position, so that the rectum 
may be well dilated by the pressure of the atmospheric air, or the 
pneumatic proctoscope should be used. The writer would suggest 
that every case sufi'ering from constipation should be examined 
first in the constipated condition, so that the location of the stools 
in the lower bowel may be made out, and the mechanical obstruc- 
tion, if present, located. Then an enema may be given, and the 
examination may proceed. 

If the cause is still undiscovered, radiography should be re- 
vSorted to for a diagnosis. The technic of the injection of bis- 
muth for radiography of the colon which has given me the most 
satisfactory results is as follows : 

After a cleansing enema is given, the patient is put in the knee- 
shoulder position, and from a pint to a quart of a mixture of two 
ounces of bismuth subcarbonate to the pint of buttermilk is 
slowly injected, using a short rectal tip. The irrigator is elevated 
two feet above the anus when the patient is in the knee-shoulder 
position. From six to ten minutes is allowed for the injection 
of the fluid, when the patient is asked to lie on his left side for 
two minutes, then on his abdomen for the same length of time, 
and then on his right side for two minutes, after which he is 
asked to sit upright for a minute or so. This allows the fluid 
to flow around to the cecum, and unless obstructed by some un- 
usual pathologic condition, will give a good radiograph. The 



CONSTIPATION AND OBSTIPATION 



75 



site of the umbilicus is marked with a coin held in place by adhe- 
sive plaster, and the picture made with the patient either lying 
on his abdomen, or standins;- with the abdomen pressed against an 




Fig. 41. Showing normal segmentation of colon up to splenic 
flexure. Descending colon contracted and atrophied. 

upright frame. Occasionally it will be found that the addition of 
some inert substance, such as fuller's earth in the proportion of 



76 



DISEASES O^ THK RECTUM 



two ounces to the pint, will help to make a better mixture. In 
place of the buttermilk, acacia or sugar added to a pint of water 
in sufficient quantity to make a syrup of the desired consistency 
will answer very nicely. 




Fig. 42. Tremendous overdistention of ascending cecum and trans- 
verse colon, due to obstruction at splenic flexure. 



If one is desirous of timing the activity of the small bowel, it 
is well to administer one ounce of bismuth subcarbonate in eight 



CONSTIPATION AND OBSTIPATION 



11: 



ounces of buttermilk by mouth, and to take frequent radiographs 
until the bismuth is seen entering the ileocecal valve (Fig. 46). 




Fig. 43. Megacolon, or hypertrophy of entire colon, with adhesions 
of prolapsed transverse colon in right iliac fossa. 

The causes of many cases of so-called constipation which were 
aggravated in type and uninfluenced by any internal medication 



78 



DISEASES 0^ THE RECTUM 



or physical therapy have been made very clear since the employ- 
ment of radiography of the intestinal tract. The great majority of 
these cases have been shown to be obstipation, the obstruction be- 
ing due to exaggeration of the normal flexures, angulation, or 
ptosis, with or without adhesions, and the colon has been found 




Fig. 44, Specimen shown in Fig". 43 after removal. 

to be the chief seat of the trouble in over 95 per cent of the cases. 
The small intestine is very seldom at fault. The accompanying 
radiographs almost tell their own story. 

Fig. 41 shows a total lack of function of the descending colon, 
due to atrophy of all of its coats. 




PLATE III. 



Giant sigmoid colon. This case illustrates the extreme limits to 
which dilatation of the colon -will g-o. 

1. Volvulus at juncture of descending and sigmoid colons. 

2. Volvulus at rectosigmoidal juncture. 

(From the anatomical laboratory of the Detroit College of Medicine, 
through the courtesy of Dr. F. N. Blanchard and N. S. Chamberlin.) 



CONSTIPATION AND OBSTIPATION 



79 



Fig. 42 shows a condition of extreme compensatory dilatation 
of the cecum, ascending and transverse colon, caused by an acute 
exaggeration of the normal angulation of the splenic flexure with 




Fig. 45. Coloptosis with angulation and adhesion of transverse 
colon — accentuation of splenic flexure. 

adhesions. This case required exclusion of the diseased portion 
and ileosigmoidostomy for its relief. 

An extreme type of dilatation of the entire colon is shown in 
Fig. 43. In this case coloptosis was also present in a marked 



80; DISEASES OF THE RECTUM 

degree, the transverse colon being" angulated and adherent in the 
right ihac fossa below the cecum. This case required the ex- 
tirpation of all of the colon from the cecum to the splenic flexure 




Fig". 46. Bismuth meal passing- from ileum to cecum (see Fig. 47). 

for relief. The section of bowel removed (Fig. 44) measured 
forty inches in length, the cecum forteen inches in circumference, 
while at the splenic flexure the circumference was eight inches. 



CONSTIPATION AND OBSTIPATION 



81 



When distended with water to the dimensions found on operation, 
it requires three and one-half quarts. This patient would go 




Fig-. 47. Same as preceding with whole colon injected with bismuth, 
showing- distention of cecum, hepatic flexure, and transverse colon, 
angulation and looping of sigmoid. 



from ten to fourteen days without a movement, and on one 
occasion, went four months. 



82 dise:ases of the rectum 

Ptosis of the transverse colon with adhesions in the pelvis, as 
well as the exaggeration of the hepatic and splenic flexures, is 



Fig. 48. Ptosis of cecum, looping and adhesion of redundant trans- 
verse colon, and fig-ure-of-eig-ht loop replacing- splenic flexure. 

well shown in Fig. 45, which was taken with the patient in the 
Trendelenburg position. 



CONSTIPATION AND OBSTIPATION 



83 



The overdistention of the colon caused by nature's efforts to 
overcome an obstruction of the sigmoid is shown in Fig. 47. 




Fig-. 49. Ptosis of cecum, acute angulation of hepatic flexure, and 
the lower part of the iUustration showing hypertrophy of second 
rectal valve. 

The acute angulations of the sigmoid will be noted^ as well as 
the distention of the hepatic flexure. The ileocecal juncture is 



84 DISE^ASKS OlP THE Rl^CTUM 

well shown. The preceding illustration (Fig. 46) was made 
from the same patient before the bismuth was injected from be- 
low, and shows the bismuth meal, given ten hours previously, 
entering the cecum from the ileum. 

In Fig. 48 we have a case of redundant transverse colon adher- 
ent and looped up under the diaphragm, and the splenic flexure 
replaced by a figure-of-eight loop of the bowel. The cecum is 
enlarged and prolapsed, and the hepatic flexure exaggerated. 

In Fig. 49 we find this acute exaggeration of the hepatic flexure 
well marked. There is also distention and ptosis of the cecum, 
and the lower part of the radiograph shows the indentation made 
by the presence of a hypertrophied rectal valve. 

The series of radiographs shown here are selected from a large 
collection in the author's possession and are presented for the 
purpose of showing the futility of treatment directed toward the 
relief of constipation without making use of all of the diagnostic 
methods at our disposal. Everyone of these cases required major 
surgical procedures for their relief, such as ileosigmoidostomy, 
resection of the diseased portions of the colon, lateral anasto- 
mosis, breaking of adhesions, mesenteric suspensions, and other 
operative measures which are not within the scope of this work. 

If, after a careful physical, proctoscopic, and radiographic ex- 
amination of the patient, none of the mechanical obstructions 
mentioned at the beginning of this chapter are present, the case 
is, in all probability, one of functional origin, and is a true case 
of chronic atonic constipation. In the course of the examina- 
tion, the dietary, habits, occupation, and the important facts about 
the patient should be elicited. When all examinations are com- 
pleted, the question of treatment presents itself. 

TREATMENT. 

Dietetic excesses and errors should be corrected, and the patient 
instructed as to the time, the quantity, and the kinds of food he 
may take. If he is not able to properly masticate his food, he 
should be referred to the dentist, and his teeth put in perfect 
shape. He should be instructed to drink from six to eight 
glasses of water in every twenty-four hours — a full glass of cold 
or hot water on arising, and also on retiring. He should drink 
plenty of water between meals, but very sparingly while eating. 



CONSTIPATION AND OBSTIPATION 85 

It is essential that he eat a sufficient amount of vegetable foods, 
such as have been enumerated above, and not to pare such fruits 
as pears, apples, and peaches before eating them. He should 
take plenty of outdoor exercise, such as tennis, golf, horseback 
riding, bicycle riding, and best of all, long walks in the open air. 
Breathing exercises should be indulged in, and in some cases 
massage of the abdominal muscles will be necessary to restore 
their tone. i 

Any local condition, such as hemorrhoids (which of themselves 
do not cause constipation but are an effect of constipation, but by 
their pressure prevent its relief by their interference with natural 
movements), should be corrected. Fissures, ulcers, or excoria- 
tions of the anus should be remedied by surgical means or treated 
locally. Proctitis should be relieved by the proper sprays, and 
medications applied locally. 

Patients who are run down may require general massage, which 
should be given by a properly qualified masseur. If the sphincter 
is abnormally tight, it should be dilated under local or nitrous 
oxid anesthesia, or by the use of a mechanical vibrator armed 
with a cone-shaped vibratode. Most important of all, however, 
the atonic rectum and sigmoid should receive internal massage. 

A great many drugless methods of treating constipation have 
been offered to the medical profession. All kinds of electric 
treatments, external massage, cannon-balls, gymnastics, vibratory 
massage, baths, and what not, have been tried, and while satis- 
factory results have been obtained from each of them in certain 
cases, there still seemed something to be desired in the successful 
treatment of chronic constipation without the use of cathartic 
drugs. 

The direct stimulation of the atonic sigmoid and rectum by 
means of mechanical dilatation has, up to the present time, given 
the best results. Rubber bags, which have been introduced 
through the proctoscope into the sigmoid and inflated, have been 
used by Turck and others with excellent results in some cases. 
Tamponing the rectum and sigmoid with cotton, wool, or gauze, 
as advocated by MacMillan, has, by its mechanical irritation of 
the mucous coat of the bowel and its simulating the normal bowel 
contents, produced satisfactory evacuation, in some suitable cases. 
The inconvenience of carrying around a tampon or inflated bag 



86 DISEASES 01? the: rectum 

in the rectum or sigmoid for from four to six hours, or more, 
has, however, been a serious obstacle to the more general use of 
these methods. Wells Teachnor, of Columbus, O., has success- 
fully treated a number of cases by simple inflation of the rectum 
and sigmoid by allowing the entrance of air through the proc- 
toscope, while the patient is in the knee-shoulder position, relying 
on the atmospheric presence for dilatation. 

Author's Method. — The author has devised and has been using 
for the past ten years a very simple pneumatic dilator for ac- 




Fig. 50. Author's pneumatic rubber dilating rectal massage bag, 
equipped with a hand-bulb. 

complishing this distention, and has achieved very happy results 
from its use. 

The apparatus consists of a specially shaped rubber bag (Fig. 
50) provided with a stem, which is slipped over the distal end of 
a Wales bougie (No. 3 to 5) ; the Wales bougie is channeled and 
contains an air vent in the handle which is closed by the finger tip 
while inflating the bag. Compressed air at a low pressure (one 
"to three pounds) is allowed to slowly enter the bag, and disten- 
tion to any desired extent is produced.^ By means of an ordinary 
cut-off valve and pressure reducer this distention can be easily 
regulated. Where the compressed-air apparatus is not avail- 



CONSTIPATION AND OBSTIPATION 



87 



able, an ordinary atomizer bulb or a small bicycle pump can be 
utilized. 

The technic of its use is as follows : 

The patient is placed in the Sims' position. The bag is twisted 
around itself on the bougie as an umbrella is rolled on its handle, 
lubricated, and passed upward into the rectum, first anteriorly 
until the anal canal has been passed, then posteriorly following 
the backward curve of the sacrum, then into the sigmoid to any 
desired height. The Wales bougie, being firm enough to carry 
the bag up into the sigmoid, and at the same time, being flexible, 




Fig-. 51. Author's rubber dilating rectal massage bag. 

A. Bag deflated. 

B. Showing the amount of inflation necessary in the average case. 

does not create any discomfort or do any injury in its passage. 
It obviates the use of the proctoscope in its introduction. When 
the bag is in position, it is slowly inflated, until the patient com- 
plains of either fulness or slight crampy pain, or a desire to move 
the bowels (Fig. 51). The air is allowed to escape by removing 
the finger tip from the air vent in the handle of the bougie. Then, 
after an interval of five or ten seconds, it is again inflated to the 
point of tolerance. This treatment is repeated for five to ten 
minutes in the average case. Then, at the time of the last in- 
flation, before removal, the cut-oflf valve, if the compressed-air 
tank is used, is disengaged, and the opening in the bougie is 



88 



DISEASES O^ THE RECTUM 



closed with the thumb; where the hand-bulb is used, the air vent 
in the handle of the bougie is closed with the finger tip, and then, 
by a to-and-fro motion, the apparatus is gently and slowly with- 
drawn. This method of removing the apparatus is of extreme 
importance as it massages the bowel as it is withdrawn, and also 
gently dilates the sphincter muscles (Fig. 52). 

This treatment is repeated daily for from five days to a week, 
and usually after the first or second treatment the patient will 




Fig-. 52. Position of patient and operator for the author's method 
of rectal massage. This is tlie best position for both the patient and 
operator in treating- chronic constipation with the author's dilating- 
rectal massage bag. 



have a small unaided movement. Cathartics and enemata are, 
of course, strictly prohibited during the treatment. 

Each day the patient will report a slightly larger and more 
satisfactory defecation, and often more than one movement in 
twenty-four hours. The patient is instructed to have a regular 
definite time for daily evacuations, and also to go to stool at any 
other time during the day, whenever he feels the slightest inclina- 
tion to have a movement. Regularity is a very important factor 
in the treatment. When the defecation approaches the normal, 



CONSTIPATION AND OBSTIPATION 89 

treatments are given only on alternate days. After six or eight 
treatments, the interval is lengthened to two days, then to three, 
and then to four, when the patient is asked to report in five or 
six days. If he reports satisfactory evacuations daily, he is 
allowed to go a week, and then, if a similar report is made, he is 
discharged as cured, but asked to return for another treatment 
on the first day on which he does not have a normal movement. 

Under no circumstances is the dilator to be given to the 
patient for self-treatment. It is impossible for a patient to suc- 
cessfully introduce the instrument or produce sufficient dilatation 
on himself to achieve results, and most of the failures reported to 
the author have been found due to this fact. The treatment must 
be given by the physician, never by the patient. 

If the case is properly diagnosed and instructions as to a 
regular time for daily evacuations and strict obedience to nature's 
calls are faithfully carried out by the patient, as well as indulg- 
ence in a proper dietary, the results from this method of treat- 
ment will be very satisfactory, as the experience of several hun- 
dred practitioners in all parts of the United States and Canada 
will testify. 

The only internal medication which has been found necessary 
in the author's experience has been the administration of extract 
of nux vomica in one-fourth to one-half -grain doses before meals 
as a tonic to asthenic or run-down individuals. Pancreatin in 
ten-grain doses before meals has been found of value in patients 
who show symptoms of intestinal indigestion. In those cases 
where starchy food is found difficult of digestion the adminstra- 
tion of taka diastase in doses of four to ten grains has been 
found of service. The author has experienced great satisfaction 
from the administration of white refined petroleum oil, also 
known as liquid albolene. 

This oil has no medicinal value whatever, is not a cathartic, or 
a food, and is not acted upon by any of the digestive secretions. 
It passes through the stomach and bowel and is expelled from 
the anus unchanged. It acts simply as a mechanical lubricant to 
the stool during its passage through the intestinal tract, softens 
hard masses which have been formed, and prevents the formation 
of others. A very satisfactory way of administering it is as 
follows : 



90 DISEASES O^ THE RECTUM 

IJ Olei gaultherise, 

Olei menthae piperitae 
Olei caryophylli, vel 

Olei cinnamomi Sij 

Petrolati liquidi giv 

Sig.: One tablespoonful at bedtime. 

The dose of the oil is gradually decreased until at the end of 
the treatment it is entirely withdrawn. From a study of the re- 
ports sent to the author by hundreds of physicians, and from his 
own experience with nearly 700 cases, he would state that, if the 
case is properly diagnosed and the treatment persisted in, a cure 
will be effected in 85 per cent of the cases. In most of the 
failures reported to the author, correspondence with the physician 
usually demonstrated the fact that mechanical obstructions were 
present, the patient was allowed to attempt the use of the dilator 
himself, or the technic of its use was not fully understood. In 
the author's experience, one case which had existed for five and 
one-half years was cured after three treatments. Another case, 
of 26 years standing, who would run two weeks without a bowel 
movement, required 40 treatments extending over a period of 
two months to effect a cure. The degree of atony will govern 
the number of treatments and the length of time required for the 
treatment. The average number of treatments in the average 
case will run from ten to twenty- four. 

Other diseases occurring coincidently with constipation have to 
be treated according to their special indications and needs. 

OBSTIPATION. 

Obstipation as defined at the beginning of the chapter is a 
purely mechanical condition, there being some pathological con- 
dition which narrows, constricts, kinks, or obstructs the bowel in 
such a manner as to offer more resistance than normal peristalsis 
can overcome. Pressure from various abdominal organs, obstruc- 
tion from coloptosis with or without intra-abdominal adhesions, 
torsion, or angulation of the bowel are conditions which can be 
remedied only by operative interference under general anesthesia, 
and do not come within the scope of this work. Obstipation, 
however, which is due to hypertrophy of the rectal valves of 
Houston, fecal impaction, or hypertrophied sphincters, in all of 
these cases is amenable to office treatment under local anesthesia. 



CONSTIPATION AND OBSTIPATION 91 

Rectal Valves. — While for several years a great controversy 
has been raised as to whether the rectal valves of Houston are 
really valves, or simply constant folds of mucous membrane, 
nevertheless the fact that hypertrophy of these structures does 
obstruct and impede the flow of the fecal current is now generally 
admitted. The number of cases reported of obstipation which 
have been relieved, only after section of hypertrophied rectal 
valves, is now so large that the operation of rectal valvotomy has 
come to be a recognized form of treatment. 

Anatomical studies of the valves in situ and sections of the 
valve studied microscopically have shown conclusively that they 
possess all the elements of a typical valve. They are not simple 
folds of mucous membrane, but are composed of: first, mucous 
membrane ; second, a fibrous tissue layer ; third, a circular mus- 
cular layer ; fourth, a longitudinal muscular layer ; and fifth, a 
subserous layer consisting of areolar tissue and fat, and contain- 
ing arteries, veins, nerves, and lymphatics. Under certain con- 
ditions these rectal valves become thickened and stiffened by the 
increased deposition of fibrous tissue, in fact, become almost 
leathery in consistency. They may or may not encroach upon 
the lumen of the bowel. They may not become increased in 
thickness whatever, but may be simply increased in area so that 
they occupy from one half to three quarters or more of the rectal 
lumen. Sometimes one valve may be enlarged, and sometimes 
two or three. This form of enlargement presents a firm and un- 
yielding barrier to the normal descent of the feces. 

Patients with so-called constipation who have run the whole 
gamut of cathartics, enemata, massage, dietetics, electricity, osteo- 
pathy, and "Christian Science" have not been relieved until they 
have had a proper proctologic examination and the enlarged rectal 
valves which were discovered reduced by valvotomy. The author 
has had repeatedly such cases referred to him, and the operation 
of valvotomy has relieved a large percentage of these cases. 

The operation as performed on most of these patients was a 
modification of that first introduced by T. C. Martin, of Wash- 
ington. It was a delicate operation, requiring considerable skill 
and special apparatus, but the results were all that could be de- 
sired. The objections were : first, that without a general anesthetic 
patients became wearied and restless before the operation was 



92 disease:s 0^ the: rectum 

completed ; second, the fact that a general anesthetic was required 
for a number of cases; third, that in cases of unusually large 
blood-vessels in the valve considerable difficulty was experienced 




Fig. 53. Author's four-inch operating" proctoscope. 




Fig. 54. Author's rubber ligature carrier or valvotomy needle. 




Fig. 55. Author's angular rectal scissors. A very useful instru- 
ment for any cutting operation performed through the operating proc- 
toscope. 

with hemorrhage; fourth, that the patient was confined in his 
house or bed or the hospital for from four or five days to a 
week. 



CONSTIPATION AND OBSTIPATION 



93 



The clamp of Gant and the Pennington cHp greatly simplified 
the Operation of valvotomy, so much so, that it conld be done in 
a very few minutes in the physician's office without any anesthesia. 
The objection to the use of these mechanical contrivances was the 
fact of the possibility of their being carried up higher into the 
bowel after cutting through, and also trauma of the rectal mucous 
membrane caused by the retention and passage of the irregularly 
shaped, hard, metallic bodies. 

Author's Operation for Rectal Valvotomy. — The author has 




Fig. 5 6. Technic of author's operation for rectal valvotomy. This 
drawing- shows the position of tlie patient in the knee-shoulder posi- 
tion, with the author's valvotomj- needle threaded with a rubber liga- 
ture transfixing the first rectal valve. 



devised an extremely simple technic, which has proved most 
satisfactory in his hands, and which by reference to the accom- 
panying illustrations can be readily understood (Figs. 53-57). 
The sphincter is first anesthetized and dilated, according to the 
technic described in Chapter X\'. The patient is then placed in 
the knee-shoulder position, and a large operating-sized procto- 
scope (Fig. 53) inserted. The author's ligature carrier or valvo- 
tomy needle (Fig. 54) is threaded through the eye at the curve 
with a rubber ligature (sizes 5 to 8, French scale). The ligature 



94 



disease;s of the rkctum 




B 




Fig-. 57. Author's rubber-ligature operation for rectal valvotomy 
(drawn from proctoscopic view). 

A. Rubber ligature in place with lead fastener ready for com- 
pression. 

B. Ligature drawn taut, and lead fastener compressed, showing 
amount of constriction. 

C. Result three weeks after operation. 



CONSTIPATION AND OBSTIPATION 95 

passes inside of the curve of the needle and should project about 
half an inch from the point. The needle, which is nine inches 
long and has a handle bent at an angle so as not to obstruct the 
view, is then passed up and around and hooked through the 
highest offending valve until the point is projected and the ligature 
can be clearly seen. This end is then grasped by means of a 
long alligator forceps, and the ligature is pulled through until 
it is outside the proctoscope. The needle is then passed back 
and around the edge of the valve and is brought down also out- 
side the proctoscope, and is then taken off the ligature. The 
ligature is now in place (Fig. 57A). Over the ends is slipped 
a lead fastener or large perforated shot, the ligature being put 
on the extreme stretch, and the shot grasped and pushed up to 
the valve tightly by means of long compression forceps and 
crushed. This puckers the valve (Fig. 57B), and constricts it 
in such a way that circulation is shut off, and the ligature sloughs 
through in from two to eight days. After the ligature has cut 
through, the edges retract so that a large U-shaped opening is 
left, which gradually still further retracts. Fig. 57C shows the 
retraction in cases in which the rectal valve contains a consider- 
able amount of fibroelastic tissue. 

The advantages of this simple technic are as follows : 

1. It can be done without any anesthetic whatever. 

2. It can be done quickly ; the whole operation should not re- 
quire more than ten minutes for three valves. 

3. It requires few instruments or appliances. 

4. The patient is not confined in bed. 

5. There is absolutely no hemorrhage; no stitches are required. 

6. The rubber ligature, being soft and non-irritating, does not 
scratch or bruise the bowel in situ or during its expulsion, and 
there is no danger of its doing damage if it should by any possi- 
bility be carried up higher into the bowel. 

7. It is simple. 



CHAPTER V. 
FECAL IMPACTION. 

This consists in the formation and retention in some part of 
the intestinal canal of a mass of hardened feces. In 70 per cent 
of the cases the fecal impaction is found in the rectum, and in 
20 per cent in the sigmoid flexure. The other 10 per cent are 
found in the upper portions of the intestinal canal, which do not 
come within the scope of this work, and will not be discussed. 

CAUSES. 

Overdistention of the bowel caused by constipation may lead 
to the formation of a pouch or diverticulum. This pouch be- 
comes filled with fecal matter, and on account of the atonic condi- 
tion of its muscular fibers, is unable to completely empty itself 
during defecation. This leads to absorption of the fluid con- 
stituents of the stool and leaves behind a hardened fecal mass, 
whose consistency ranges from that of stiff clay to calcareous, as 
in enteroliths, or fecal concretions, which are composed largely 
of lime salts. Bits of bone, fruit and vegetable seeds, fruit 
stones, indigestible vegetable fiber, concretions of bismuth, salol, 
magnesia, or other insoluble drugs, taken internally, may become 
the nidus of a fecal concretion, which in turn is frequently the 
underlying cause of fecal impaction. Gallstones may also be re- 
sponsible for their formation. 

SYMPTOMS. 

The symptoms of fecal impaction are those of obstipation, 
coming on rather suddenly with more or less intestinal distention, 
accompanied with pain in the rectum, and extending to the left 
inguinal region, and frequently shooting down the left leg. The 
patient will complain of a frequent desire for stool, but inability 
to accomplish the same on account of a sense of weight and 
blocking-up of the rectum. If the impaction is low he may 
feel it impinging on the anus following the effort at expulsion. 

96 



I^ECAL IMPACTION 97 

The pressure on, and irritation of, the mucous membrane, caused 
by the presence of this hard foreign body, starts up a hypersecre- 
tion of mucus and causes ulceration of the bowel. This causes 
in many instances a diarrhea, characterized by frequent, small, 
irritating, watery, and mucous stools, which often contain blood 
and frequently pus. 

Cases have been reported in which the impaction has become 
channeled, where, after a period of almost complete obstruction, 
the patients have had stools apparently normal. In cases where 
the impaction occurs in a pouch, or diverticulum, this may also 
occur. In these cases, however, the feeling of weight, heaviness, 
and discomfort in the sigmoid or rectum is still present, and there 
is more or less tenesmus, and an unsatisfied feeling after stool. 

In women, pressure from a large impaction on the uterus, or 
ovaries, may cause anterior displacement and symptoms of uterine 
irritation. Through direct pressure and reflexly, the bladder be- 
comes irritable, and frequent micturition results. Patients suffer- 
ing from impaction usually present, in addition to the foregoing, 
symptoms of autointoxication, such as dizziness, headache, coated 
tongue, foul breath, indigestion with or without vomiting, abdom- 
inal distention, lack of ambition, and general malaise. 

DIAGNOSIS. 

The diagnosis is not difficult. By rectoabdominal palpation, 
the round, or often nodular, mass can be made out in the lower 
left inguinal region, or in the rectum itself. To the examining 
finger in the rectum, it may be hard and nodular, or, owing to its 
being in a pouch or diverticulum and almost completely sur- 
rounded by mucous membrane, it may give an impression of being 
an extrarectal pelvic tumor. 

On direct examination with the proctoscope with the patient 
in the knee-shoulder position, and the rectum inflated, the impac- 
tion can be easily made out. It is important in using the proc- 
toscope to carefully manipulate the instrument so as to see be- 
hind each rectal valve, as not infrequently the pouching occurs in 
any of these locations, and the contained impaction, or concretion, 
is almost completely hidden from sight. If palpation discloses a 
mass in the sigmoid flexure, examination with the sigmoidoscope 
may be employed to demonstrate the impaction or concretion to 



98 DISI^ASES OF THE RECTUM 

the eye. It is important to determine by either ocular inspection, 
or examination with a sound, whether we are dealing with an im- 
paction of clay-like consistency, or a hard concretion, as the treat- 
ments of the two are necessarily somewhat different. 

TREATMENT. 

The treatment of this condition consists in the prompt removal 
of the impacted mass. Situated in the rectum and reached by the 
finger, it may be easily broken up without the use of any instru- 
ment, providing it is of recent origin and its consistency not 
firmer than stiff clay. When it is situated beyond the reach of the 
finger, or if of too firm a consistency to be easily manipulated, the in- 
jection of 8 or 10 fluid ounces of liquid albolene, olive oil, or cotton- 
seed oil, with the patient in the knee-shoulder position, and this 
allowed to remain for 12 hours, will often so soften and disinte- 
grate the mass that it can be passed without any difficulty. In 
many cases this will bring the impaction down so low into the 
rectum that it can be broken up with the finger or a dull spoon 
curette used through the proctoscope, with the patient either in the 
lateral or lithotomy position. 

The most reliable method is, however, the injection of peroxid 
of hydrogen in solutions varying in strength from 10 to 25 per 
cent. With the patient in the lateral position 2 to 4 ounces of 
peroxid solution are injected through a soft-rubber rectal tube in- 
serted up to the impaction. The tube is allowed to remain in 
place, and at the end of 5 minutes the rectum irrigated, when it 
will be found that the impacted mass has been disintegrated 
through the mechanical action of the liberated gas and is easily 
washed out. Several injections of the peroxid solution may be 
necessary, but if persisted in, it may be relied upon to do the work. 
When the mass is of long-standing and so hard that it takes on 
the characteristics of a true concretion, it may become necessary 
to dilate the sphincters under local anesthesia and to break up 
the mass with a short- jawed lithotribe passed through an opera- 
ting-sized proctoscope. When the concretion is larger than 1^^ 
inches in its widest circumference it is safest and best to admin- 
ister nitrous oxid, divulse the sphincters, crush the concretion, and 
remove the mass with forceps. 

After the impaction has been removed, the patient should be 



^ECAIv IMPACTION 99 

put on a liquid, absorbable diet for two or three days. Liquid 
albolene should be administered in doses of one or two teaspoons- 
ful four times daily, and regular daily defecations encouraged. 
The atonic condition of the rectum should be overcome by the 
use of the author's pneumatic massage bag, as outlined in the 
chapter on the treatment of chronic constipation. 



CHAPTER VI. 
PRURITUS ANL 

Pruritus ani is the most annoying symptom, short of pain, 
which may accompany any disease of the rectum or anus. It is 
because of the intense suffering and discomfort which it causes, 
when present, that it has been given the prominence and impor- 
tance that is accorded it of treating it as if it were a disease by 
itself. 

Pruritus ani, which may be an accompanying symptom of so 
many different diseases, in reaHty should not be considered alone 
as a disease any more than rectal pain or rectal hemorrhage. Like 
constipation, however, it is such an important symptom, and often 
the only apparent symptom of some diseased condition, that it 
has been thought wise to emphasize it in this chapter, and to 
speak of some of the conditions which most frequently cause it. 

CAUSES. 

Pruritus ani may be caused by or accompany every known anal 
or rectal disease, as well as many diseases affecting other organs 
or general in character. In other words, it may be caused by: 

1. Any disease of the rectum or anus. 

2. Any skin disease aft'ecting the anal region. 

3. As a reflex from diseases of the bladder, prostate gland, 
uterus, ovaries, vagina — in fact, any part of man's or woman's 
urogenital apparatus. 

4. General or constitutional diseases. 

5. Dietary disturbances. 

6. Parasites. 

7. Irritation from clothing, detergents, or moisture. 

The discussion of the various anal and rectal diseases which 
present pruritus ani as a symptom will be taken up in the respec- 
tive chapters devoted to those diseases. The skin diseases most 
commonly affecting the anal region are marginal eczema, herpes, 
erythema, scabies, and folliculitis. 

100 



PRURITUS ANI. 101 

Stone in the bladder is not infrequently accompanied by an 
itching of the anus and perineum. Chronic prostatitis, vesicu- 
litis, urethritis, phimosis, and cystitis may also be accompanied 
by itching of this region. Any disease of the uterus or adnexa 
may cause itching in the region of the anus, and many times the 
symptom of pruritus is caused by some irritating discharge from 
the vagina. 

Pediculi, threadworms (O.vyuris venniculavis) , itch-mite 
(Acanis scabei), ringworm {Trichophyton) , are the most com- 
mon parasites manifesting their presence in the anal region by 
itching. 

Among the diseases of a more general character which are fre- 
quently found to be the causes of itching at the anus are : diabetes, 
malaria, uric acidosis, nephritis, tuberculosis, syphilis, and hys- 
teria. Many patients suiter from an attack of pruritus ani after 
partaking of alcoholic stimulants in excess. In others, the ex- 
cessive use of tobacco, coffee, tea, and spices also conduces to the 
production of this symptom. Some patients are subject to attacks 
of pruritus ani only during the strawberry season, while others 
have an attack every time they partake of sea foods, particularly 
of the shellfish variety. Some patients possess an idiosyncrasy 
toward some one food or class of foods, and it is the indulgence 
in this class only which brings on an attack of pruritus ani in 
these particular individuals. 

In many cases the itching is caused by mechanical irritation of 
the skin surrounding the anus or by the use of coarse or harsh 
material in cleansing the anus after defecation. Some writers 
claim that the printer's ink on newspapers acts as a special irri- 
tant to the anus. The wearing of underwear colored with dyes 
of inferior quality, as well as the pressure of clothing which fits 
too snugly in the perineal region ; the irritation caused by exces- 
sive sweating, particularly in stout individuals, and those who are 
forced to work in a high temperature, such as engineers, stokers, 
molders, and gas workers, are often responsible for the produc- 
tion of pruritus ani. Personal uncleanliness in this region is 
too often found to be the cause of pruritus, as in other parts of 
the body. 

There has been a condition described by some writers as 
idiopathic pruritus ani, because of the presence of itching of the 



102 



Disi^AS£;s 01^ the: RKCTUM 



anus alone as the symptom, and the discovery of no other appar- 
ent cause for its existence. I do not beHeve that there is such a 
thing as idiopathic pruritus ani. I have seen cases in my prac- 
tice where after the most painstaking and thorough search no 
cause could be found for the itching; yet I believe there was a 
local cause, only it was not discovered. The fact that some of 
these cases are cured empirically by stretching of the sphincter 
muscles would seem to indicate that there might be some local 
condition irritating the nerve-endings which was mechanically 





^^C Wf^ ' 


M 


^BtMtScx!^' 




^^^^ 




1 


W-\ ^ 




,,. \ 


W^. -..-!! k^ 



Fig-. 58. Pruritus ani. Characteristic cracking- around the margin 
of the anus and at the posterior commissure, and the area of irritation 
of the apposing surfaces of the buttocks. 



relieved by the stretching process. A perineuritis of the anal 
nerves is undoubtedly present, either as a primary or secondary 
factor in many cases of pruritus ani. Most cases of pruritus 
ani will be found to accompany a proctitis, which may involve 
a small circumscribed area or the whole proctal lining. 

D. H. Murray, of Syracuse, believes that the cause of all 
cases of pruritus ani will be found in an infection from the 



PRURITUS ANI. 



103 



Streptococcus fcccalis, and has made extensive studies to support 
his views. 

DIAGNOSIS. 

The appearance of the anus and perineum in the patient 
suffering from pruritus ani is quite characteristic — the skin 
around the anus being thrown into numerous, deep folds radiat- 
ing from the anal orifice (Fig. 58). In those cases accompanied 
by more or less moisture, the skin is white, soggy, and more or 




Fig-. 59. Pruritus ani. showing- excoriation of anterior and posterior 
commissures. 

less macerated, with, here and there, small raw areas where the 
skin has been denuded of epitheHum by scratching. In other 
cases of not so long-standing, we find the skin around the anus 
normal in color but dry with a tendency to scale. The cutaneous 
folds are not so deep, but in the sulci are found small cracks in 
the skin and extending up into the mucous membrane. In many 
cases, particularly in stout individuals, a long raw fissure or 
crack may be found extending along the median raphe anter- 
iorly to the scrotum or posteriorly into the median perineal crease 



104 



dise:ashs o^ the: re:ctum 



for a distance of from one to four or five inches. The skin sur- 
rounding the anus and these various cracks may be reddened and 
excoriated for a great distance from the lesion (Fig. 59). It 
may extend some distance up on the abdomen or down the thighs 
(Fig. 60) and legs to the knees. In cases of long-standing the 
skin surrounding the anus loses its elasticity and becomes hard, 
thick, and leathery. This condition is in reality due more to the 




Fig. 60. External integumentary hemorrhoids accompanied by 
pruritus ani. This shows the extent to which cutaneous irritation may 
go. in this case extending up over the sacrum and down nearly half- 
way to the knees. 



scratching and rubbing by the patient in his futile efforts to re- 
lieve the condition than to any pathological condition brought 
about by the itching itself. 

Pruritus ani may mean anything from a slight feeling of un- 
easiness or irritation in the anal region to an intense burning, 
almost crazing, itching characteristic of the most aggravated 



PRURITUS ANI. 105 

types. There are several things characteristic about this itching : 

1. It is usually more intense at night. 

2. It tends to become progressively worse. 

3. It is not relieved by scratching. 

4. In spite of the fact that the sufferer soon realizes that the 
scratching or rubbing only aggravates the condition, he per- 
sistently and constantly continues to scratch. 

While every disease aft'ecting the rectum or anus may be re- 
sponsible for the production of pruritus ani, those that most 
commonly cause it are fissure of the anus, ulcer, particularly of 
the anal canal, anal fistula, either complete, blind, or burrowing, 
hypertrophied papillae, diseased crypts, and proctitis. The reader 
is referred to the respective chapters describing these conditions 
with their diagnosis and treatment. Every case of pruritus ani 
demands the most careful investigation into the patient's habits, 
occupation, and mode of living, as well as the most thorough 
examination of the anus, rectum, sigmoid, and adjoining organs. 

Unfortunately in some few cases where pathologic conditions 
have been found in the anus or rectum, which where thought 
to be the cause of pruritus ani, their removal has not relieved 
the itching. In fact, on account of the healing by granulation 
and the resultant scar tissue, some cases have been reported in 
which the itching has been aggravated. It is important, there- 
fore, to be very guarded in the prognosis and not promise a cure. 

TREATMENT. 

The treatment of pruritus ani is of course the treatment of 
the disease, whether local or general, which causes it ; and the 
reader must use his general medical knowledge in the treatment 
of diseases of a constitutional nature and in the treatment of 
the general diseases mentioned above, as that does not come 
within the scope of this work. The treatment of the symptom, 
itching, must be simply palliative, while the treatment of the con- 
dition which is responsible for the itching is being carried out. 
If due to any of the rectal or anal diseases mentioned herein, 
follow out the treatment as laid down in the various chapters. 
If due to any skin disease of the part, such as marginal eczema, 
consult any good work on dermatology and treat it as you would 
any other skin disease in any part of the body. The author has 



106 DISEASES OF THE RECTUM 

found the following ointment a most successful one in these 
cases : 

I^ Pulveris calaminae 5ii 

Zinci oxidi 3i 

Hydrargyri chloridi mitis gr. xv 

Phenolis tl]? xx 

Adeps lan« hydros! §i 

Misce et fiat unguentum. 

This is applied freely to parts, after cleansing and thoroughly 
drying, after each bowel movement and at night. In some cases 
where there is considerable moisture the following powder may 
be used instead of the ointment: 

IJ Chloretone gr. xxx 

Pulveris calaminse 3ij 

Zinci oxidi 3j 

Hydrargyri cliloridi mitis gr. xxx 

Misce et fiat pulvis. 

This is applied in the same manner as the ointment. 

Herpes and erythema of the skin surrounding the anus may be 
relieved by the application of the compound stearate of zinc with 
balsam of Peru or stearate of magnesia. The parts must be pro- 
tected, and the surfaces kept from rubbing against each other by 
absorbent cotton. Scabies is best treated by the ordinary sulphur 
ointment of the pharmacopeia. Where inflammation of the hair 
follicles exists with the formation of pustules, they must be opened, 
washed with a 25 per cent solution of peroxid of hydrogen, and 
then dressed with a compress of any of the standard antiseptic solu- 
tions, boracic acid being used by the author. Where the Pediculi 
pubis are present, liberal applications of blue ointment or tincture 
of larkspur should be used. In ringworm the Trichophyton 
may be reached by sulphur ointment. Where threadworms are 
present, lime-water enemata will very quickly relieve. They should 
be injected twice daily, using from 4 ounces to ^ pint at each 
sitting, and capsules containing one-half grain calcium sulphid, 
given three times daily before meals. 

In cases where excessive indulgence in smoking, alcoholic stimu- 
lants, and articles of diet that produce or aggravate itching is 
responsible, it is obvious that these indulgences must be inter- 
dicted. Where the occupation or habits are at fault, changes are 
necessary in order to bring about the best results. The remedies 



PRURITUS ANI. 107 

or combination of remedies which are recommended for pruritus 
ani are many. Blackwash is recommended by many authorities 
as an old reliable remedy. Tuttle considers carbolic acid in oint- 
ment, or solution from 5 to 20 per cent, as the most generally 
applicable of all drugs for the relief of pruritus ani. He rec- 
ommends this prescription : 

I^ Phenolis 3ii 

Acidi salicylici 3i 

Glycerin! 3i 

Misce secundem artem. 

Sig.: Apply to the parts with camel's hair brush or cotton swab 
softened in hot water. 

Cripps recommends : 

IJ Phenolis 3ss 

Unguenti hydrargyri 3ii 

Unguenti petrolei §i 

Another ointment of which he speaks very highly is : 

I^ Extracti conii 3i 

Olei ricini. . . .* 3i 

Unguenti lanolini q. s. ad 5i 

Where ointments do not agree Kelsey recommends this lotion : 

I^ Sodii boratis 3ii 

Morphinse hydrochloridi gr. xvi 

Acidi hydrocyanici diluti Sss 

Glycerini Sii 

Aquae q. s. ad Sviii 

Cripps also recommends a lotion containing two grains of 
bichlorid of mercury to the ounce of lime water as an applica- 
tion after thoroughly washing the parts with soap and water. 

Gant recommends as a hard ointment the following: 

I^ Phenolis gr. xx 

Mentholis gr. x 

Camphorse gr. x 

Sevi Si 

Misce. 

Sig. : Apply freely two or three times daily after cleansing the parts. 

In the preparation of the above he advises to melt the suet 
and when partly cooled to add the other ingredients. He espe- 
cially cautions against adding oil, as the ointment should be quite 
hard, the object being to form a coating over the parts which 
will not be penetrated by the secretions. Citrine ointment 
(unguentum hydrargyri nitratis) is highly recommended by Gant 



108 DIS^ASE:S 0? THE RECTUM 

in cases where it is necessary to restore the circulation, and the 
indurated skin to its normal color and suppleness. Through the 
suggestion of Dr. L. H. Adler, Jr., Gant uses it in the following 
manner: After the parts have been bathed in warm water, the 
citrine ointment (which may have to be weakened in some cases 
by the addition of lard) should be spread on several thicknesses 
of gauze, applied, covered with oiled silk, and held in place by 
a snug T-bandage. This ointment should be kept on constantly, 
or in some cases it may be found necessary to alternate it with an 
ointment containing 20 grains of calomel to an ounce of petro- 
latum. 

In the author's experience for the mere relief of itching, com- 
presses or enemata of water as hot as can be borne have given the 
greatest relief in the greatest number of cases. Sometimes cold 
acts better than hot. An ointment containing 25 per cent of 
chloretone in white cold cream has proved very efficacious in the 
author's hands for the same purpose. 

In cases presenting a fissured condition of the anus, skin, and 
mucous membrane, the application of 100 per cent solution of 
nitrate of silver will cause a desquamation of the entire surface 
within 24 hours. Then a 5 per cent scarlet-red ointment in 
vaselin is applied on alternate days. The use of a mechanical 
vibrator, with a cone-shaped vibratode, for five minutes at a 
time, using from 5,000 to 7,000 strokes a minute, and inserted as 
far as can be borne by the patient, will often afford much relief. 
Firm pressure by means of a hard-rubber rectal plug affords 
relief to some individuals where all other measures have failed. 
It must be borne in mind that, while any of the remedies men- 
tioned herein are being used to relieve the itching, they are but 
palliative, and the permanent relief of the itching comes only 
after the diagnosis and cure of the condition which causes it. 
This must be diagnosed and studied for treatment; and if the 
condition is not amenable to non-surgical treatment or operative 
treatment under local anesthesia, it is more likely a case for the 
proctologist than for the general practioner, and his aid should be 
called in. 

If the itching is caused by the discharge from rectal cancer or 
from the small, shallow ulcerations of the mucous membrane be- 
tween the sphincters — which Wallis, of London, claims is the 



PRURITUS ANI. 109 

cause of 90 per cent of all cases of true pruritus ani — then the 
indicated surgical procedures should be carried out, whereupon 
the itching will be relieved. In cases where the Streptococcus 
fcecalis, described by Murray, is found, the administration of 
autogenous vaccines should be tried, along with the measures 
advocated above. 

The writer would suggest that one should carefully 
read over the chapters on proctitis, constipation, anal fissure 
and ulcer, fistula, hemorrhoids, and hypertrophied papillae, as 
well as the chapter on the examination of the patient, before at- 
tempting to treat a case presenting pruritus ani as a symptom. 

In many cases, the local condition seems to imperatively demand 
surgical treatment, and in many of these patients prompt relief is 
experienced after the indicated operation. The author describes 
below those which he can safely recommend. 

Surgical Measures. — In those cases of pruritus ani in which 
the skin surrounding the anal orifice has been hypertrophied and 
thrown into heavy folds and the sulci between these folds fissured, 
irritated, and giving forth an irritating discharge, a simple sur- 
gical procedure will often give relief. E. A. Hamilton, of 
Columbus, O., advises the removal of these hypertrophied skin 
folds under local anesthesia, and reports very good results from 
his method. 

Where there are only two or three folds involved, they can all 
be removed at one sitting. Otherwise, the operation may have 
to be done at different sittings, with intervals between long enough 
to allow of complete healing of the ones already operated on. 

After cleansing, sterilizing, and shaving the parts, the patient 
is placed in either the lithotomy or lateral position. Each fold 
to be removed is injected from its outermost point with yg to 
j4- per cent solution of eucain lactate, or 1 per cent solution of 
quinin and urea hydrochlorid. After allowing ten minutes for 
the anesthetic to take full effect, the fold is removed by grasping 
its apex with a pair of forceps and cutting it out at its base with 
a sharp scissors curved upon the flat, or by elliptical incisions with 
the scalpel. The other fold or folds are treated in like manner, 
and the wound surfaces allowed to fall together without suture ; 
and they usually heal by first intention. The bowels are kept 
confined for three days, and then moved by the administration of 



no DISEASES 01? THE RECTUM 

a heaping teaspoonful of compound licorice powder on the even- 
ing of the third day, followed the next morning by an oil enema 
of six or eight ounces. Applications of bovinine three or four 
times daily to the wound surfaces will greatly hasten healing. 
After two or three weeks another two or three folds, preferably 
those situated opposite to those previously removed, can be treated 
in a like manner, and the same technic carried out until all the 
redundant tissue has been removed. 

Where the pruritus is most persistent at the posterior com- 
missure of the anus, and examination at that point shows either 
nothing but a thickened and irritated area extending a short way 
into the anal canal, or shallow excoriations at the anal margin 
which are neither fissures nor ulcerations, the removal of a kite- 
shaped flap of skin and mucosa at this point is often followed 
by relief from the symptoms. 

The technic is as follows : 

After cleansing, sterilizing, and shaving the parts, a point 
three quarters of an inch behind the posterior commissure is 
selected, and ^ per cent solution of eucain lactate, or 1 per cent 
solution of quinin and urea hydrochlorid, injected so as to include 
a triangle whose apex is the point of injection and whose base 
extends from one-quarter to one-half inch to either side of the 
posterior anal commissure. The infiltration of the anesthetic 
solution should extend up into the anal canal far enough to in- 
clude any excoriated or irritated areas. A triangular flap of 
skin is dissected up by means of a sharp scalpel or sharp-pointed 
scissors curved on the fiat — starting at the point of injection 
and extending to the posterior margin of the anus. The incisions 
then should be brought toward each other so as to meet at a point 
one quarter of an inch above the diseased area in the anal canal. 
The latter part of the operation makes a short, broad triangle, 
whose base is the same as the base of a longer one on the skin 
surface. This leaves a denuded kite-shaped area. The skin is 
brought together by three or four No. 1 or 2 chromicized 
catgut sutures, boro-chloretone powder applied, and the wound 
protected with a gauze pad held in place by adhesive strips (Fig. 
61). The care of the bowels is the same as that outlined above, 
and the after-treatment consists of daily cleansing of the parts 
and reapplication of boro-chloretone, or compound stearate of 



PRURITUS ANI. 



Ill 



zinc powder. Healing will take place in from four to seven 
days, and the relief experienced by the patient after this pro- 
cedure in selected cases is very satisfactory. 

Bali^'s OpERAtiox. — One of the most successful surgical 
measures available for employment under local anesthesia, for 
the relief of persistent pruritus ani, is the ingenious operation 
devised by Sir Charles Ball, of Dublin. 

As described in Ball's work on ''The Rectum,'' its employment 




Fig-. 61. A simple and satisfactory rectal dressing-, consisting of a 
gauze-covered cotton pad and two strips of adhesive plaster. 



is advocated under general anesthesia. The author, however, 
has been able to perform the operation with brilliant results by 
the employment of local anesthesia. The object of the opera- 
tion is for the purpose of dividing all the sensory nerve-twigs 
supplying the skin of the anus, anal canal, and circumanal region, 
which arise from branches of the third and fourth sacral nerves, 
come down to the levator ani muscle, and reach the skin by per- 
forating" the external sphincter. 



112 



dise:ases of the rectum 



The technic as employed by the author is as follows : 

The patient is given a hypodermic injection of % grain of 

morphin and %5o grain of atropin and is placed in the left 

lateral or Sims' position, and the area surrounding the anus 

cleansed, shaved, and sterilized. 

An ounce of ^ per cent solution of beta-eucain lactate, or the 

same quantity of }4 per cent solution of quinin and urea hydro- 




Fig-. 62. Sharp-pointed scissors curved on the flat. 




Fig-. 



T-forceps. 



chlorid, should be prepared and in readiness. Ten or twelve sharp- 
pointed curved needles, each threaded with No. 2 chromicized 
catgut; a couple of sharp, small-bladed scalpels; sharp-pointed 
scissors curved on the flat (Fig. 62) ; two pairs of T-forceps 
(Fig. 63), and two or three hemostats; and the syringe for in- 
jecting the solution are all the instruments required. Selecting 
the point about one-half inch behind the posterior extremity of 



PRURITUS ANI. 



113 



the lines of incision in Fig. 64, the skin and subcutaneous tissue 
are infiltrated. From this point the area, included inside the 
lines in P'ig. 64 and for one-half inch beyond, is distended until 
complete anesthesia is secured up to the anorectal juncture. The 
presence or absence of skin sensibility to pain should be tested 
before starting to operate. The incisions, as outlined in the 
above illustration, are then made with a sharp knife down 




Fig-. 64. Ban's operation for pruritus ani. 
cision on either side of the anus. 



Elliptical lines of in- 



through the skin to the subcutaneous tissue. The area included 
between the lines of incision should be of elliptical shape, and 
about twice as long in the antero-posterior direction as it is broad 
in the lateral, with the anal canal as its center. With the patient 
in the left lateral position, the incision on the left side is made 
first, the inner flap of skin is grasped with T-forceps, and by 
rapid and careful dissection with the scalpel is raised from the 



114 



DISEASES OF THE RECTUM 



surface of the external sphincter muscle and freed up to the 
anorectal juncture. The anterior and posterior pedicles between 
the ends of the incisions are freed from the subcutaneous tissues 
as well. In other words, all connections between the funnel- 
shaped cutaneous and mucocutaneous covering of the anus and 
anal canal are freed entirely from their underlying tissues (Fig. 
65). Ball advocates the use of the scissors for this work, but 
the author has found he can work much more rapidly and with 




u.-3-.-j5rC-''j£g'. i 



Fig-. 65. Ban's operation fur inveterate pruritus ani. Method of 
dissecting- the flaps and of dividing the terminal cutaneous nerve- 
twigs, which, for the purpose of clearness, are somewhat exaggerated 
in the drawing. — After Ball. 



more assurance of dividing all the sensory nerve-twigs by the 
use of a sharp scalpel. All bleeding should be controlled by 
pressure with dry gauze, and the flaps sutured again to the sur- 
rounding skin with silkworm or No. 2 chromicized catgut. 
Four to six interrupted sutures are all that are necessary for each 
incision. Firm pressure by wedge-shaped gauze pads is brought 
to bear against the region operated on, and the dressings held in 
place by adhesive plaster and a T-bandage. This operation, by 



PRURITUS ANI. 



115 



dividing all of the sensory branches supplying the area most 
often involved, immediately renders this region superficially an- 
esthetic, and the pruritus is relieved at once (Fig. 66). Cutane- 
ous sensation returns after a few months, but pruritus is per- 
manently relieved. 

Louis J. Krouse, of Cincinnati, has modified this operation by 
substituting six or eight radiating incisions for the elliptical ones 




Fig-. 66. Ball's operation for pruritus ani. The crossed lines show 
the area to which the wound is undercut, and the outside limits of 
anesthesia produced by the operation. 



used by Ball (Fig. 67). His technic possesses the advantage of 
less possibility of interference with the circulation and vitality of 
the flaps, and suturing is often not required. 

Afte:r-Tre;atmi:nt. — The after-care consists in keeping the 
patient on an absorbable liquid diet and keeping the bowels con- 
fined for four or five days, when they are moved by an oil enema. 



116 



dise:ase:s 0^ the: re:ctum 



The parts are carefully washed and kept protected at all times by 
the liberal use of compound stearate of zinc or magnesia powder. 
The patient should be kept in bed for a day or two and then al- 
lowed to be up and about, but not to resume his regular occupation 



i 


y^Wf^ 


te 





Fig. 67. Krouse's radiating- incisions for his modification of Ball's 
operation. 

for a week or ten days. In the experience of the author, the re- 
sults following this operation have been most happy, particularly 
in those old chronic cases where all other forms of treatment have 
been tried and found wanting. 



CHAPTER Yll. 
AXAL FISSURE AND ULCER. 

Anal fissure, or fissura in ano, is probably responsible for more 
acute pain, suffering, and discomfort than any other lesion of its 
size occurring in the human body. The fissure, as its name im- 
plies, is a crack or elongated ulceration, occurring most frequently 
at the posterior commissure of the anus (Fig. 68). 




Fig-. 68. An aggravated case of anal fissure, showing sentinel pile. 



CAUSE. 



Fissures are caused by trauma, 
duced by passing an unusuallv 



expelling a 



foreign 



The traumatism may be pro- 
large stool, introducing or 
body, straining, sneezing, coughing, or 
by faulty instrumentation. Fissures usually occur singly. 
When more than one is present it is an evidence, as a general 

117 



118 



DISE:aSKS 01^ THE RECTUM 



rule, of the presence of tubercular, gonorrheal, or syphilitic in- 
fection, or a run-down condition caused by some of the wasting 
diseases (Fig. 69). 

In men, in 90 per cent of the cases, the fissure will be found 
in the vicinity of the posterior anal commissure; in women, in 
about 60 per cent — the other location being in the region of the 
anterior commissure. 

The reasons for the posterior commissure being the most fre- 




i ' Fig-. 69. Multiple anal fissure. 

quent location for fissure are: The fact that on account of 
the concavity of the sacrum the curvature of the rectal and anal 
canal is such that the greatest force during the expulsion of the 
stool is toward the posterior commissure; also, the fact must 
be remembered, that the fibers of the sphincter ani muscle run 
parallel to each other posteriorly (Fig. 4) to the coccyx, and this 
is the direction of the anal line of cleavage. Moreover, this is a 
constant location for one of the crypts of Morgagni, and the 



ANAL I^ISSURE AND ULCE:r 



119 



tearing-down of a semilunar valve at this point (Fig. 70) is often 
the starting-point in the production of fissure. 

Any inflammatory condition which wall cause a moisture and 
softening of the anal skin will render it more liable to be injured 
during a movement and fissure produced. A fissure is, in reality, 
a longitudinal ulcer. When the fissure has been in existence for 
some time, it tends to become chronic, the tissues surrounding it 
become indurated, and the skin is pushed down in the form of a 




Fig-. 70. Anal fissure resulting- from the tearing-down of one of 
the crypts of Morgagni, with the formation of a sentinel pile. 



tag which becomes hypertrophied (Figs. 68 and 70) in such a 
way as to give rise to a thick crescentic fold known as the 
"sentinel pile." Fissures are frequently found accompanying 
hemorrhoids, the ulceration being located in the sulcus between 
two hemorrhoidal masses. Not infrequently, when the fissure 
is of the chronic variety, it is accompanied by a polypus, which, 
by hanging down into the fissure from its upper extremity, tends 
to keep it irritated and prevents it from healing. One reason 
advanced for the fact that fissures or ulcerations in the anal 



120 DISEASES OF THE RECTUM 

canal tend to become chronic rather than to heal is the fact that 
the anal canal is lined by a layer of thin transitional epithelium, 
which is neither mucous membrane nor skin, and is poorly sup- 
plied with blood. This fact, and the action of the sphincters, 
keeping the parts in motion, tend to prevent good healing. 

DIAGNOSIS. 

The diagnosis of fissure is comparatively easy. A patient, pre- 
senting himself with a history of sharp, cutting, often excruciat- 
ing pain, accompanying the passage of a hard stool, and the ap- 
pearance of hemorrhage following the passage, is in itself almost 
pathognomonic of a fissure. Added to this, the history of pain, 
usually very severe, as well as the appearance of blood with each 
succeeding stool, is corroborative. When the patient also com- 
plains of a beating, throbbing pain, lasting from half an hour to 
several hours following the passage, and painful spasmodic con- 
tractions of the anal sphincter, or pruritus ani, the diagnosis of 
anal fissure is without an examination almost conclusive. How- 
ever, one can never take the diagnosis of any condition in the 
anal or rectal region for granted, without making a thorough ex- 
amination. Therefore, after obtaining such a history, the patient 
should be placed on the table in the lateral position for examina- 
tion. 

Upon separating the buttocks, the first thing that will usually 
attract attention, except in acute cases, is the presence of a sen- 
tinel pile. This gives a clue at once to the location of the fissure, 
which will be found, as above stated, just at either side of or at 
the posterior anal commissure. Inasmuch as the entire sphincter 
is inflamed, hypertrophied, and exquisitely sensitive to the touch, 
it may be necessary, before a satisfactory examination can be 
made, to anesthetize the parts. 

However, if by gentle traction on the skin, just below the 
sentinel pile, an abrasion is disclosed, extending upward into the 
anal canal, the diagnosis of fissure is confirmed. If this pro- 
cedure causes the patient much suffering, it had better be aban- 
doned until the sphincter has been anesthetized according to the 
technic outlined in Chapter XV. 

In cases which have existed for some time, the fissure, instead 
of presenting a red angry appearance, may be covered with a 



ANAI. FISSURE AND ULCE^R 121 

grayish or yellowish exudate. The reason that a fissure or ulcera- 
tion of this region is so exquisitely tender is because of the ex- 
posure of some of the numerous nerve-endings with which this 
area is so generously supplied. The only other condition with 
which fissure is liable to be confounded is hemorrhoids, and that 
only from the patient's standpoint. Not infrequently, practi- 
tioners have been led into the error of taking the patient's word 
for the fact that he was suffering from hemorrhoids, because of 
the symptoms of pain at stool and hemorrhage; therefore the 
author would reiterate, at the risk of becoming tiresome, that a 
rectal examination must be made in every case, when the exact 
diagnosis can be easily made. 

TREATMENT. 

The treatment of anal fissure resolves itself into palliative and 
operative. Many cases of fissure of recent origin are entirely 
amenable to non-surgical treatment. The first thing to do is to 
relieve constipation, which is done by putting the patient on a 
suitable diet, excluding all articles which leave much residue and 
cause bulky stools. The administration of white petroleum oil, 
suitably flavored, in doses of from one-half to an ounce daily, 
will soften the stools to such an extent as to make them easy of 
expulsion, though not liquid and irritating. 

Where the fissure is shallow, and is not accompanied by the 
formation of a sentinel pile, the application of a swab moistened 
in 2 per cent eucain solution, for four or five minutes, followed 
by the application of pure ichthyol to the surface of the fissure, 
is very efficacious. This is repeated every second day. In the 
meantime the patient is instructed to carefully cleanse the parts 
after bowel movements and to apply, by means of a long-nozzled 
ointment tube (Fig. 71), the following: 

I^ Chloretone gr. xxx 

Thymolis iodidi gr. xx 

Ichthyoli gr. xxx 

Adeps lanse hydros! q. s. ad Sss 

Misce et fiat unguentiim. , 

Occasionally, where the fissure is very superficial and consists 
merely of a crack in the mucous membrane, a single application 
of a saturated solution of nitrate of silver will be sufficient. This 



122 



DISEASES OF THE RECTUM 



acts by causing a protective covering of albuminate of silver to 
be formed and effects the cure. Proper attention to the condi- 
tion of the bowels, cleanliness, and the application of stearate of 
zinc powder are all the after-care that is required. 

The daily applications of mild solutions of nitrate of silver, 
alum, copper sulphate, or the use of the caustic stick are not to 
be advised, because they only keep up the irritation and destroy 
the new granulation tissue as fast as it is formed. The stronger 
solution of silver nitrate, as mentioned above, by its sudden 
coagulation of the albumin of the tissues when it comes in con- 




Fig-. 71. Method of applying" ointment to the anus from a long^- 
nozzled coUapsible lead tube. 



tact with the wound, causes the formation of an impermeable 
protective covering for the granulating surface beneath, and more- 
over, is far less painful than the milder solutions. The application 
of 5 to 10 per cent scarlet-red ointment every third day is an ex- 
cellent stimulant to the formation of new epithelium. Suppositories 
for the relief of fissure do not appeal to the author ; inasmuch as 
fissure is always found in the anal canal and the action of a 
suppository is exerted only in the lower rectal cavity, he fails to 
see where any direct relief can be obtained from suppositories 
in this condition. Moreover, it is doubtful whether an ointment 



ANAL I^ISSURE: and ULC^R 



123 



applied with the finger is of any value, for it certainly cannot 
be applied high enough to reach any but the most dependent por- 
tion of the fissure ; yet it is astonishing how often the patient 
suffering with fissure is dismissed with a prescription for an 
ointment. 

Surgical Treatment. — The best, surest, and quickest treat- 
ment for anal fissure is incision or excision. The author knows 
of no operative procedure in the practice of proctology from 




Fig-. 72. Injection of anal fissure at the base of its sentinel pile 
at the anterior commissure. 



which more satisfactory results are achieved than the incision or 
excision of an anal fissure. Under local anesthesia, this is very 
easily and readily accomplished, and the results are invariably 
all that could be desired (Fig. 72). In some cases, where the 
fissure is of recent origin, not accompanied by much inflammatory 
infiltration of the surrounding tissues, simple divulsion is all that 
is necessary to effect a cure. Divulsion of the sphincter, how- 
ever, can be accomplished to the extent of temporarily paralyzing 



124 



DISEASES OF THE RECTUM 



the muscle, only by the use of a general anesthetic. This can 
be best, quickest, and most safely accomplished by the use of 
nitrous oxid. 

Incision. — The technic of incision of anal fissure is as follows : 
After anesthetizing- the sphincter and dilating it, as outlined 
in the chapter on local anesthesia, a dram or so of Yiq per cent 
solution of eucain, or 1 per cent solution of quinin and urea 
hydrochlorid, is injected below and around the fissure in such a 
way as to raise it up so that it is resting on a "water-bed." After 
waiting at least ten minutes for anesthesia to become complete, an 




Fig-. 73. Simple incision of fissure in right posterior lateral quad- 
rant of anus. 



incision is made from the extreme upper end of the fissure down 
through the center and extending beyond the lower extremity for 
a quarter of an inch into the skin (Fig. 73). The incision should 
be so made that its upper or inner extremity will be the 
shallowest, and it should become deeper until at the lower or skin 
end it is from one-quarter to one-half inch in depth, slanting in 
such a way that the upper or shallowest part will be the first to 
heal and the lower the last — thus providing excellent drainage. 
The unhealthy surface should be lightly cauterized, a suppository 
containing two grains each of chloretone and thymol iodid, or 



ANAIv FISSURE AND UI^CER 



125 



ten grains of quinin and urea hydrochlorid, inserted, and a single 
strip of plain gauze placed in the wound. 

At the end of 24 hours the gauze is removed, but the patient's 
bowels are not allowed to move for three days at least. In the 
•meantime, he is kept on liquid diet, and the administration of white 
petroleum oil is started on the evening of the second day, so that 
the first stool will be soft and unirritating. It is advisable on 
the evening before a stool is desired to administer a level tea- 
spoonful of compound licorice powder, and the first thing the 
following morning, to inject through a small rubber catheter six 
or eight ounces of olive oil into the rectum to insure a soft and 
easv movement. 




Fig-. 74. Sharp-toothed or prong'ed forceps. This is a very useful 
instrument in many anorectal operations, and while originally designed 
as a tonsil forceps, is of great value in proctologic work. 



The after-care consists in keeping the parts clean, the bowel 
movements soft, and the patient up and about after the first 24 
hours. If granulations become flabby or unhealthy in appear- 
ance, a single application of saturated solution of sulphate of 
copper or of nitrate of silver is usually sufficient to stimulate 
healthy healing. On the other hand, if the patient is in a run- 
down condition and the healing slow, the insertion of a one-half- 
inch strip of gauze soaked in bovinine, twice daily, will nourish 
the healing tissues and bring about a speedy result. Scarlet-red 
ointment, 5 to 10 per cent, is also of great value in these sluggish 
cases. 

While in many cases this procedure will be sufficient, it will 



126 



DISEASES O^ THE RECTUM 



not answer where the fissure is of long-standing, or if surrounded 
by an area of infiltration, or where there is a well-developed sen- 
tinel pile, or a polypus accompanying the fissure. Often a fissure 
after incision will not heal, because of the fact that the mucous 
membrane dips down into the wound and tends to keep its edges 
apart. To obviate this, and to make sure that all the diseased 
tissues are removed, the author excises instead of incises, when 
operating for anal fissure. 




A B 

Fig. 75. Author's technic for the excision of anal fissure. 

A. The dotted lines show the line of incision both on skin sur- 
face and mucous membrane. 

B. Showing- V-shaped bed left after removal of the flap contain- 
ing the fissure; the dotted lines show the shape and the direction 
of the incision inside of the anus. 



Author's Operation. — With the patient prepared and anes- 
thetized as for the incision operation (with the exception that 
the area of infiltration anesthesia is made more extensive so as 
to include all the induration surrounding the fissure), he proceeds 
as follows : 



ANAIv FiSSURi: AND ULCER 



127 



The fissure is grasped at its upper extremity with sharp-toothed 
forceps (Fig. 74), and two longitudinal incisions are made, one 
on either side of the fissure, starting from one-eighth to one- 
fourth inch to either side of its upper or inner extremity, and 
being made in such a manner that they meet underneath the 
fissure in its median line, forming a V-shaped trench (Fig. 75), 
which is one eighth of an inch deep at its upper extremity and 
one fourth of an inch wide; and at the outer or skin portion its 




Fig-. 76. Operation for excision of anal ulcer. Note the manner 
in which the incisions are brought to a point at upper and lower ex- 
tremities of wound. 



width is from one half to three fourths of an inch and its depth 
from one-fourth to one-half inch. This disposes of the entire 
fissure, with its indurated edges, and the sentinel pile as well. 
It also allows the fissure to heal quickest at the bottom and pre- 
vents any overgrowth of the mucous membrane or dipping-down 
of the edges. If a polypus is situated at the upper extremity, 
the incisions are carried up to include it; and as the fissure is 
dissected up from below, a ligature is thrown around the base of 



128 dise:ases of the: rkctum 

the polypus, tied, and the fissure and polypus cut away en masse. 
The after-treatment is the same as outlined for the incision opera- 
tion. This operation, in the hands of the author, has been so 
satisfactory that it is his routine treatment for all fissures not 
amenable to non-surgical treatment. 

ANAL ULCER. 

Whatever has been said of anal fissure in regard to treatment 
by non-surgical measures is equally applicable to anal ulcer, the 
only distinction between the two conditions being a question of 
the shape of the ulceration — the fissure being elongated, while 
the other ulcers of the anus are round or irregular in outline. 
In ulcers which do not respond to the applications advocated for 
fissure, the injection of a few drops of Yiq per cent eucain solu- 
tion, or 1 per cent of quinin and urea hydrochlorid, under the 
ulcer is advisable, and a light curetting of its surface will often 
be followed by marked relief. Where the ulcer is of long-stand- 
ing, the excision of the indurated tissues surrounding, as well 
as the ulcer itself, should be accomplished, following the same 
technic as outlined for the excision of fissure, varying the direc- 
tion of the incisions to correspond to the shape of the ulcer (Fig. 

The after-treatment following excision of an anal ulcer is 
exactly the same as that, outlined above, following fissure. It 
is the watchful after-care of the conscientious physician, follow- 
ing many of these minor anal operations, which is responsible for 
the good results — for often a well-executed operation is nullified 
in its results by neglectful, slovenly, or misdirected after-care. 
Oftentimes the after-care of patients following these operations 
is overdone rather than the reverse, and meddlesome interference 
accomplishes more harm than the operation does good. 



CHAPTER VIII. 
ABSCESS OF THE ANORECTAL REGION. 

The region of the anus and rectum is peculiarly prone to in- 
fection and abscess formation, for several reasons: The unusual 
amount of cellular tissues surrounding the rectum; the lavish 
blood supply of this region; the constant presence in the rectum 
of pyogenic bacteria ; the traumatism from unusually large or 
hard feces ; foreign bodies, such as spicules of bone, fruit pits, 
seeds, and other articles which have been ingested. The rich 
lymphatic supply of this region is of great importance in the pro- 
duction and extension of septic inflammation. Skin diseases 
around the anus, particularly those which affect the hair follicles, 
inflammation of external hemorrhoids, the irritation from cloth- 
ing or harsh detergents, disease of the crypts of Morgagni, rectal 
ulceration and anal fissure — all may form the starting-point for 
the formation of an abscess in this region. 

Septic infections of the anorectal region have been divided into 
different classes by different authors. Tuttle classifies them as 
follows : 

Subtegumentary 
Circumscribed \ Superficial .....< Tegumentary 



{ 



inflammations I [ Ischiorectal 

or abscesses., i (Retrorectal 

[ Profound. ..... K Superior pelvirectal 

( Interstitial 

{Diffuse perirectal cellulitis 
Gangrenous perirectal 
Cellulitis 

Of the circumscribed inflammations or abscesses, only those 
which are located below the levator ani muscle are amenable to 
treatment under local anesthesia, and will be considered by the 
author under the head of tegumentary or perineal abscesses ; 
perianal, marginal, or subtegumentary abscesses; submucous or 
intermural ; and ischiorectal abscesses (Fig. 77). 

129 



130 



disi:ases 01? the: rectum 



TEGUMENTARY ABSCESS. 

The tegumentary, or perineal, abscesses are really nothing more 
than pustules, or furuncles of the skin surrounding the anal 




Fig-. 77. Anorectal abscesses. 

1. Submucous or infermural abscess. 

2. Ischiorectal abscess. 

3. Marginal or subcutaneous abscess. 

4. Tegumentary or cutaneous abscess. 

orifice, or a pustular inflammation of the hair follicles. They 
may be brought about by anything which causes irritation of the 
parts, such as extensive perspiration, discharge from the anus or 



ABSCESS 01? THE ANORECTAL REGION 131 

vagina, chafing' from the clothing, infection by the finger-nails in 
scratching, personal uncleanliness, or the use of harsh detergent 
materials. The condition may range from a simple acne of the 
parts to the formation of numbers of typical boils. These cause 
a slight sense of irritation, smarting or itching, and cause more 
discomfort when the patient is sitting or walking than any inter- 
ference with the function of the bowel itself. Occasionally 
several of these small abscesses may run together, forming a 
typical carbuncle. This, however, is rather rare in this region. 
There is usually a slight rise of temperature, a degree or two at 
the outside, and more or less irritability of the patient's temper. 
There are no constitutional symptoms. 

Diagnosis. — With the patient in the lateral posture, these ab- 
scesses will be seen occurring either singly or in groups as 
rounded reddened swellings from the size of a large pinhead to 
a hazel nut, with or without a point of suppuration showing in 
its center. 

Treatment. — The treatment consists of spraying each abscess 
with ethyl chlorid and opening with a sharp bistoury. After 
allowing the pus to escape, the cavity is swabbed with 95 per cent 
carbolic acid. Daily washing- of the part with warm saturated 
solution of boracic acid and dressing with boro-chloretone powder 
will usually be all that is necessary in the line of after-treatment. 
The parts should be washed after defecation and protected with 
sterile gauze, and the clothing worn loose so that there is no 
pressure or chafing from that source to keep up the irritation. 

If there is a tendency for these little skin infections to recur, 
it is advisable to treat the patient with a bacterial vaccine made 
from the predominant germ responsible for the infection. In 
most cases this will be found to be the Staphylococcus pyogenes 
aureus or alhiis. 

SUBTEGUMENTARY OR MARGINAL ABSCESS. 

The most common abscess developing in the region of the anus 
is that which occurs deeper under the layers of the skin or lining 
membrane of the anus, described in the above classification as 
subtegumentary, also known as perianal or marginal abscess — 
also as subcutaneous, submucous, or intramural, depending upon 
the kind of tissue under which the abscess develops. While often 



132 



DisE^ASKs oip the: Rectum 



their starting-point can be traced to a fissure or ulcer, a broken- 
down thrombotic pile, or a diseased crypt, or the traumatism due 
to a bit of bone or other swallowed foreign body, nevertheless, in 
many cases, the point of infection cannot be determined — leading 
us to the conclusion that the abscess is caused by extension 




Fig-. 78. Characteristic sitting posture assumed by patients, suf- 
fering from anorectal disease. 



through the lymphatic system, from some more or less remote 
injury or disease in this region. They may occur at any age, but 
are less common in children. 

Symptoms. — Occasionally, abscesses which occur in this region, 



absce;ss o^ thk anorectal region 133 

particularly the submucous variety, have developed to a con- 
siderable size without causing any other symptoms than a sense 
of uncomfortableness or fulness in the lower rectum, noticed 
particularly during defecation. Usually, however, the patient 
complains first of sharp darting pains in the rectum, which are 
soon followed by an aching, throbbing pain which is persistent 
and gradually increasing. This aching extends to the sacral 
region, and the pain often shoots down one or both legs, even 
to the heel. The patient often complains of difficulty of urina- 
tion. Defecation is always painful, and on account of the feeling 
of fulness in the rectum, is deferred by the patient as long as 
possible. The pulse rate increases in rapidity, and the tempera- 
ture rises from one to four degrees. The patient cannot sit com- 
fortably and rests his weight on either buttock — a characteristic 
posture of patients suffering from acute rectal disease (Fig. 78), 
which in itself is almost diagnostic. 

An abscess may often develop in from 24 to 36 hours, and 
occasionally will rupture before the patient is really aware of the 
severity of the trouble. These are the cases which terminate in 
the formation of fistulse. 

Examination. — With the patient in the lateral posture, often 
nothing can be determined by ocular inspection unless the abscess 
be situated at or outside the margin of the anus, when it will 
appear as a rounded swelling, reddened in color, situated usually 
at either side of the posterior anal commissure. On digital ex- 
amination, it can be definitely outlined, and its extent determined. 
If seen early, a definite point of fluctuation cannot be made out, 
but the whole abscess has a hard, doughy feel. It is extremely 
tender on palpation, and on account of the accompanying spas- 
modic contraction of the sphincter muscle, it is often very hard to 
examine. 

Treatment. — The treatment of the subcutaneous or marginal 
variety is very satisfactorily accomplished under local anesthesia. 
If the abscess is situated at or below the juncture of the anus 
and rectum, it will not be necessary to anesthetize the sphincter 
muscle. With the patient in the lateral or lithotomy position, 
the parts are scrubbed, shaved, and sterilized, and the skin over 
the abscess injected with ^/i per cent solution of beta-eucain 
lactate. A point one-half inch below the abscess proper is 



134 DISEASES o^ THE re;ctum 

selected for the first injection, and the injection carried upward 
so that a wheal or welt a quarter of an inch to half an inch wide, 
and extending the entire length of the abscess, is formed. After 
waiting fully ten minutes for the anesthetic to take effect, 
an incision is made from one extreme of the abscess to the other 
in a direction at right angles to the anus, and the pus allowed to 
escape. It is then irrigated with sterile water or normal salt 
solution, and after breaking down any dividing walls, so as to 
convert the abscess into one cavity, it is swabbed out with equal 
parts of tincture of iodin and carbolic acid ; a light gauze drain 
inserted, and a sterile dressing applied. The patient is not 
allowed to arise from the table for five or ten minutes after the 
operation, when he is slowly assisted to his feet, and after a 
few minutes in a chair will be able to go on his way. 

It is advisable to keep the patient on an absorbable diet for a 
couple of days and not allow the bowels to move during that 
time. The wound should be dressed daily, being irrigated with 
plain sterile water or salt solution and lightly packed with gauze. 
When the author says ligJitly packed, he means the gauze should 
be inserted sufficiently firm to keep the wound edges zvell sepa- 
rated and yet touching against the lining of the cavity so lightly 
as not to interfere zvith its contraction during the healing process. 

At the end of the fourth or fifth day in the average case all 
drainage can be discarded except a strip of gauze inserted merely 
to keep the wound edges apart. This must be renewed daily as 
long as any purulent discharge persists. The best protective 
powder to use to keep the discharge from irritating the surround- 
ing skin is compound stearate of zinc with balsam of Peru or 
magnesium stearate. 

SUBMUCOUS ABSCESS. 

The submucous or intermural variety occurs underneath the 
mucous membrane covering the lower rectum, and may be 
found at any point in the circumference of the rectum. Those 
located in the anterior wall are usually accompanied by disturb- 
ances of urination. In fact, oftentimes patients are unable to 
urinate at all and have to be catheterized. This variety is 
diagnosed by digital examination — the well-lubricated finger 
gently inserted through the anus while the patient is asked to 



ABSCKSS O^ the: anorectal REGION 



135 



bear down. A rounded mass may be felt within an inch or inch 
and a half of the anal outlet, either of a doughy consistency or 
distinctly fluctuating. By gently sweeping the finger from side 
to side, the outlines can be made out, and its extent determined. 
With the short anoscope, the diagnosis can be further confirmed 
(Fig. 79), and not infrequently the point of infection determined.. 




Fig-. 79. Proctoscopic view of submucous abscess of the i^ectum. 



Occasionally, the abscess may extend down to the integument 
beyond the anus, forming a submucocutaneous abscess. 

Diagnosis. — The diagnosis, after both digital and ocular ex- 
amination, is very evident. Given the symptoms of rise in tem- 
perature, rapid pulse, aching, throbbing, pain coming on more or 



136 DISEASE:S 01^ THE RECTUM 

less suddenly in the region of the anus or lower rectum and re- 
maining, becoming more persistent and increasing in severity, 
with the presence of a circumscribed painful swelling, these make 
the diagnosis of abscess in this region conclusive. 

Treatment. — When the abscess is of the submucous variety 
and situated above the internal sphincter, it will be necessary to 
anesthetize the sphincter, according to the technic outlined in 
Chapter XV. After washing out the rectum with saturated 
solution of boracic acid, the patient is placed in either the lithot- 
omy position, if the abscess is situated on the anterior wall, or 
the lateral position, if located on the posterior or lateral wall. 
After the parts are washed, shaved, and sterilized and the 
sphincter anesthetized, it is slowly dilated, and a Sims' retractor 
inserted at a point opposite the abscess and held by an assistant. 




Fig\ 80. De Vilbiss rectal speculum. This instrument is useful in 
many anal operations, on account of the fact that its blades may be 
opened parallel to each other and it can be self-retaining". 

In the absence of an assistant, a De Vilbiss rectal speculum (Fig. 
80) will answer, as it is self-retaining. The mucous membrane 
covering the abscess is injected with a %o P^i" cent solution of 
eucain lactate, or 1 per cent solution of quinin and urea hydro- 
chlorid, until the tissues are blanched over the entire abscess. 

After waiting ten minutes for the anesthetic to take effect, the 
abscess is opened by a longitudinal incision extending from its 
extreme upper end down well below its lower extremity. The 
pus is allowed to drain out, when the cavity is irrigated with 
normal saline solution or sterile water. All dividing walls are 
broken down so that the abscess is converted into one cavity. 
Tt is then swabbed out with 95 per cent carbolic acid or equal 
parts of carbolic acid and iodin, and gauze lightly inserted, which 
should extend out through the anus. In some cases it is advis- 
able to insert a rubber drainage tube about the size of a lead 



ABSCESS OF* the: anorectal REGION 137 

pencil, which tube should also extend an inch outside the anal 
canal. 

The after-care is similar to that advised for the subcutaneous 
variety, especial care being taken to see that the abscess is kept 
healing from the bottom, and that no ramifications form during 
the healing process. The patient is allowed to be up and about 
immediately after the operation, and is properly kept up on ac- 
count of better drainage in the upright position. It is this 
variety of abscess which, if allowed to open without surgical in- 
terference, forms the blind internal fistula. It is an important 
thing to remember, in this form of abscess particularly, that the 
incision should be carried well below the lower extremity of the 
abscess, so as to allow good drainage. 

ISCHIORECTAL ABSCESS. 

Ischiorectal abscesses are the most extensive variety which can 
be treated under local anesthesia, and not all of these, by any 
means, are favorable cases. The author would lay down the 
rule that no abscess of the ischiorectal region whose upper ex- 
tremity is over two incJies from the anal skin, and zvhose extent, 
size, and location cannot he definitely outlined by bimanual pal- 
pation, should be operated unless under a general anesthetic. 

Ischiorectal abscesses start, grow, and extend with great 
rapidity on account of the loose cellular tissues, in which they form, 
offering little or no resistance to their spread. They occur at 
either side of the rectum, and occasionally surround it. They 
are formed either from the puncture of the rectal walls by spicules 
of bone, bristles, or other ingested foreign substances, or from 
diseased Morgagnian crypts or infection which is carried by the 
lymphatic system. They have been known to follow operations 
on the rectum and anus, or injury caused by faulty instrumenta- 
tion in making a rectal examination. 

Symptoms. — The constitutional symptoms are similar to those 
which accompany the subcutaneous or submucous abscesses, with 
the exception that the pain is more deeply seated, the sacral ach- 
ing more severe, and the symptoms in general approaching more 
nearly those of a general septic infection. The patient often 
suffers from chills, wnth a high fever, severe headaches, backache, 
fetid breath, languor, loss of appetite, and more or less prostra- 



138 



DISKASKS 01? THE RECTUM 



tion. The pain localizes itself on either side of the rectum, unless 
there is a simultaneous infection on both sides. Defecation is 
so painful that the patient gives up all attempts at it and fre- 
quently also is unable to urinate. If the abscess has existed 
longer than 48 hours, some redness of the skin will be observed, 
varying in degree according to the nearness of the abscess to 
the integument. 

Diagnosis. — Bimanual rectal palpation, with one finger in the 




Fig-. 81. Line of incision for opening an ischiorectal abscess. 



rectum and the other hand pressing toward it just outside the 
anus (Fig. 81), will disclose a hard elongated mass, often pear- 
shaped, which is extremely painful, and gives the characteristic 
doughy or boggy feeling of an abscess. A point of fluctuation 
oftentimes can be made out at the lower extremity of the abscess. 

The diagnosis is readily made on bimanual examination. The 
swelling caused by the abscess may be so great that it is prac- 
tically impossible to introduce the proctoscope into the rectum. 

Treatment. — After the rectum has been flushed with a satu- 



ABSCKSS O^ THE ANORECTAI. REGION 139 

rated solution of boracic acid, the patient is placed in the lithotomy 
or lateral position, according to the location of the abscess, and 
the parts washed, shaved, and sterilized. The sphincter is an- 
esthetized, according to the technic outlined in Chapter XV, and 
the skin over the abscess, as well as the anal lining membrane, is 
infiltrated with ]/\ per cent solution of eucain lactate, or 1 per 
cent solution of quinin and urea hydrochlorid. After the infiltra- 
tion of the skin, the subcutaneous tissues down to the abscess are 
injected with the quinin-urea solution, care being taken not to 
penetrate the abscess cavity with the hypodermic needle. The 
infiltration should be carried well into the lower rectum. A Sims' 
retractor is inserted at a point opposite the abscess and held by 
an assistant, or the De Vilbiss speculum used, and opened to its 
fullest extent. With a sharp-pointed bistoury an incision is made 
from the outermost point of the abscess on the skin toward the 
anus, so that the incision is at right angles to the anal canal. The 
opening should be made wide enough so as to thoroughly drain 
the abscess cavity, and only if necessary, should be extended 
through the sphincters into the anus. 

Where the abscess cavity can be well exposed by an incision 
which stops short of the sphincter and there are no ramifications 
of the cavity, it will not be necessary to enter the rectum, and 
the author, as a rule, would caution against making an opening 
in the rectum unless a communication already exists in the form 
of a fistula. All trabecuUe and partition walls should be broken 
down so that the abscess is converted into a single cavity, and 
it should be irrigated with saline solution or sterile water. The 
incision at the outermost point of the abscess cavity should be as 
wide or wider than the cavity itself. After irrigating the cavity 
sufficiently, gauze soaked in balsam of Peru should be gently in- 
serted so as to keep its walls apart. A dressing is applied, and 
the patient advised to keep in the recumbent position, lying pref- 
erably on the operated side for 24 hours. 

At the end of that time, the packing is removed, and about 
two thirds of the quantity of gauze used in the first dressing 
lightly inserted. At each succeeding daily dressing the amount 
of gauze is lessened until the abscess cavity has healed up from 
the bottom. If the granulations become flabby or unhealthy at 
any time, they should be touched with a saturated solution of 



140 dise:ase:s o^ the: rectum 

copper sulphate or a 25 per cent solution of silver nitrate. The 
application of pure ichthyol every second or third day, while 
somewhat painful, is of extreme value in promoting good granu- 
lation. 

Where it has been found necessary to carry the incision into 
the rectum and sever the sphincters, care should be taken to 
arrange the drainage in such a way as to prevent the skin or 
mucous membrane from growing down into the wound, and pre- 
vent the reuniting of the sphincter as the abscess cavity heals. 

If this should happen, however, in spite of all precautions, anes- 
thetize the part by the application of a swab soaked in 4 or 5 per 
cent eucain solution for five minutes, keeping up pretty steady 
pressure on the parts. Then with a pair of sharp-pointed scis- 
sors, curved on the flat, trim back all redundant tissue to the sur- 
face of the skin or mucous membrane as the case may be. 

In the treatment of all suppurative conditions of the anorectal 
region, the author would caution his readers to refrain from 
attempting to operate on any case in which there is the slightest 
doubt of his ability to complete the operation under local anes- 
thesia. One must be sure of the size, location, and extent of the 
abscess, and it must be definitely outlined and definitely circum- 
scribed in order to be amenable to treatment under local anes- 
thesia. 



CHAPTER IX. 
ANAL FISTULA. 

A fistula may be described as a tubular suppurating tract, com- 
municating with or connecting the mucous membrane of the anus 
or rectum, and the integument contiguous to the anal outlet. 
Fistulae are of several different varieties, which will be described 
below. A fistula is the result of an abscess in the anal region, 
which has either been untreated and allowed to rupture, or when 
opened by the surgeon has, through insufficient, careless, or im- 
proper after-treatment, been allowed to contract without being 
made to heal from the bottom. The only exception would be 
a fistula caused from a punctured wound, either traumatic or 
surgical. 

Anal fistula is often spoken of as either tubercular or non- 
tubercular. While the author realizes that tuberculosis is a 
factor to be seriously considered in the discussion of fistula, he 
will reserve his remarks on this particular variety of fistula until 
farther on in the chapter. What is said regarding fistula below, 
therefore, must be understood to mean the non-tubercular 
varieties. i , i 

The reason that an abscess degenerates into a fistula in this 
region, rather than to completely heal, is due to two factors 
peculiar to its location. The most important is the fact that, 
due to the natural motion of the anus and rectum in the act of 
expulsion of gas or feces, and the dilatation and contraction of 
the sphincter muscles, the parts are not allowed to remain at rest, 
and the surfaces are prevented from adhering to each other. 
Added to this is the important fact that mucus and feces enter 
the abscess cavity from the rectum and their constant passage 
tends to keep the tract open and prevent healing. A fistula, 
therefore, is in reality the tubular contracted remains of an ab- 
scess, and is lined by a pyogenic membrane as was its parent 
abscess. 

VARIETIES OF FISTULA. 

The variety of a fistula depends on the location and kind of 
abscess which preceded it. They are divided by some authors 

141 



142 disease:s of the rectum 

into complete and incomplete. A complete fistula is one which 
gives a direct communication between the bowel and the surface 
of the skin, somewhere in the region of the anal opening. An 
incomplete fistula is either one which has an opening into the 
bowel alone or one which opens through the integument alone. 
Complete fistulse (leaving out of consideration those which 
communicate with other organs, such as the bladder, vagina, or 
urethra) are divided into horseshoe fistulse and multiple fistulge. 
The horseshoe fistula is characterized by its having one opening 
in the anal canal, usually situated between the sphincters at the 
posterior commissure, and surrounding the anus, communicates 
with the skin by two openings — one on each side of the anus. 
A multiple fistula is one which has one or more internal openings 
and numerous branching channels opening by many external 
openings on the skin. The incomplete varieties are known as 
the blind internal fistulge, which are characterized by the fact 
that they open into the bowel only, and blind external fistulse, 
whose only openings are through the skin. 

A form of fistula known as the submucous fistula is one which 
has two openings, both opening on mucous membrane, and is 
usually found just inside the anal canal. The most common 
location for the internal opening of a fistula is at the posterior 
commissure of the anus and between the sphincter muscles. In 
this chapter only those varieties of fistulse which are amenable 
to treatment under local anesthesia will be discussed : viz., simple 
complete fistula, blind external, blind internal, and submucous 
(Fig. 82). 

SIMPLE COMPLETE FISTULA. 

This is the commonest form of fistulse met, and is the 
remains of a subcutaneous or ischiorectal abscess, and consists 
of a straight or slightly curved channel running from the anal 
canal or some point in the rectum a little higher up to the outside 
skin — usually opening within one or two inches of either side, 
and below the anal aperture. The external opening may be at 
any point on the skin in the vicinity of the anus, but the points 
mentioned are the usual sites. 

Symptoms. — The symptoms are a sense of irritation or an 
itching of the anal region, pain during defecation, and the 



ANAI. ^ISTUIvA 



143 



presence of a purulent discharge. If for any reason one of the 
openings should become plugged up, there is some distention, 
and pain from pressure. 

Diagnosis. — The diagnosis of fistula should always be in mind 




Fig-. 82. Anorectal fistulse. 

1. Blind internal fistula. 

2. Blind external fistula. 

3. Complete direct fistula. 

4. Submucous or submucocutaneous fistula. 

when on examination of a patient a papule is seen on the per- 
ineum or buttocks, from which a drop of pus exudes or can be 
pressed out. This is the characteristic appearance of the ex- 
ternal opening of a fistula. With the patient in the lateral posi- 



144 



DISE:ASE:S 01^ THE RECTUM 




Fig-. 83. Direct complete anal fistula. The probe is seen enterinsr 
the external or cutaneous opening, while directly above it its blunt- 
tipped extremity is seen emerg-ing- from the anus. 




Fig. 84. Angular fistulous tract. The upper portion of the fistula 
has been opened, and the probe can be seen entering the lower portion. 
The end of the probe can be seen emerging from the left upper quad- 
rant of the anus. 



ANAL FISTUI.A 145 

tion and the index finger of one hand over the external opening, 
the index finger of the other should be inserted with the palmar 
surface directed toward the posterior commissure. Often by 
the pressure with the finger in the rectum a drop of pus will be 
forced out through the external opening. By carefully feeling the 
region between the anal canal and the outside opening, one will 
often make out the cord-like feel of the fistulous tract. Of ten- 




Fig-. 85. Radiograph of simple direct complete fistula. 

times the internal opening is extremely difficult to find. Upon ex- 
amination with the author's fenestrated anoscope, or the anoscope 
with the oblique aperture, a small reddened spot, often raised 
somewhat from the surface, will be detected, from which pus 
can be squeezed out. When this point is discovered digital ex- 
amination will reveal the induration underneath the surface, 



146 DISEASES OF THE RECTUM 

which discloses the direction of the fistulous tract. If, after 
careful examination of the entire circumference of the anal canal 
and lower rectum, no internal opening can be detected, the in- 




Fig-. 86. Complicated complete fistula. This ran ud nearly six inches 
behind the rectum. Its branching- channels M^ould have been missed 
had it not been for the radiograph. 

jection into the external opening of peroxid of hydrogen, methy- 
lene-blue solution, milk of magnesia, or bismuth paste will 
assist one in locating the internal opening by the point of appear- 
ance of the solution inside the anus or rectum. 



ANAL FISTULA 147 

The probe may be used to diagnosticate the presence and direc- 
tion of a fistulous tract, but in order to be of any value, it must 
be very fine and extremely pliable — one made of annealed-silver 




Fig-. 87. Multiple fistula communicating with urethra. This case 
had twelve external openings besides the one into the urethra. 

suture wire is the best for this purpose (Figs. 83, 84). One must 
be extremely careful in introducing a probe into a fistulous tract, 
for it is very easy to force it through the walls of the fistula 



148 DISE^ASES O? THE RKCTUM 

or into the rectum, thus creating a false passage. If the probe 
does not pass easily, it is better to discard it than to use any 
force in its use. If there is a suspicion that the fistula communi- 
cates with the bladder or urethra, the injection of a mild solution 
of methylene blue 1 to 5 per cent into the organ will settle the 
question. If such a communication be present, the colored solu- 
tion will exhibit itself at the fistulous opening in very short 
order. A five-grain capsule of methylene blue administered by 
mouth will, if a communication with the bladder or urethra 
exists, show a blue discoloration of the fistula in a few hours. 
The injection of a paste made from one part of bismuth subnitrate 
and two parts of vaselin, heated, into the external opening of a 
fistula, followed by a stereoscopic radiograph, is, without doubt, 
the best and most accurate diagnostic agent in our possession 
today. The existence of tracts, otherwise undiscoverable, is 



Fig-. 88. Grooved director. 

thus demonstrated, and the operation can be definitely planned 
in advance (Figs. 85-87). 

Treatment. — The treatment of fistula, as a general thing, is 
best accomplished under general anesthesia, because many times, 
upon laying open what appears to be a simple fistulous tract, 
ramifications and extensions may be found which would necessi- 
tate more dissection than is possible to accomplish satisfactorily 
under local anesthesia. A case of simple, direct fistula, however, 
which is not tortuous, and in which the whole channel with its 
external and internal opening is made out by the diagnostic 
methods mentioned above, may be treated under local anesthesia 
in any one of three ways. 

Incision. — Simple incision will sufiice in some cases where the 
fistula is not deeply seated. After the bowels have been washed 
out with a saturated boracic-acid solution and the area around 
the anus scrubbed, shaved, and sterilized, the sphincter is anes- 
thetized, according to the technic outlined in Chapter XV, and 
the tissues over the fistula injected to the point of blanching with 



ANAIy I^ISTULA 



149 



^ per cent solution of eucain, or 1 per cent solution of quinin 
and urea hydrochlorid. A probe-pointed grooved director (Fig. 
88) is then passed through the fistula from the external to the 
internal opening, and all the tissues between the director and the 
surface are divided by a curved bistoury passed from without in- 
ward, thus freeing the director and laying open the entire fistula. 
A pledget of cotton soaked with a 2 per cent solution of eucain 
is pressed into the incision and is held firmly against the opened 
fistulous tract for two or three minutes. It is then removed, and 
the diseased surface lightly curetted with a sharp spoon curette, 




Fig\ 89. Right-angled incision for simple direct anal fistula. Tn 
a simple fistula by which the bowel communicates with the external 
integument crossing the external sphincter in an oblique manner, the 
external sphincter is cut at right angles by the method outlined. 



the incision loosely packed with gauze, and an anodyne supposi- 
tory inserted and a dressing applied. 

Unless the direction of the fistulous tract is in a line at right 
angles to the fibers of the sphincter muscle, it must not be opened 
by a single straight incision. It is an invariable rule that any 
incision which must sever any or all of the fibers of the sphincter 
should cross it only at right angles (Fig. 89) in order to prevent 
incontinence afterward. The incision, therefore, must be so 
directed that it never severs the sphincter muscle in an oblique 



•150 



dise:ase:s 01? the: rectum 



manner. Where the fistula is located just below the skin or 
mucous membrane and does not involve the sphincter, this rule 
does not necessarily hold good. 

Excision. — In some cases it will be found advantageous, in- 
stead of simply opening the fistulous tract, to excise the entire 
canal. This is the most satisfactory operation when it can be 
successfully carried out, and should be the operation of choice 
in all straight, uncompHcated fistulae which are situated so that 




Fig-. 90. Author's technic for removing fistulous tract in toto. The 
lateral incisions are so directed that a V-shaped bed is left, which can 
occasionally toe approximated by sutures. 

the tissues surrounding the fistula can be successfully infiltrated. 
After the usual preparation of the patient and anesthetization 
and dilatation of the sphincter muscles, the tissues surrounding 
the fistula are anesthetized. A V^ per cent solution of eucain is 
injected into the skin along the line of incision up to the opening 
in the anal canal ; then the surrounding tissues are distended with 
a 1 per cent solution of quinin and urea hydrochlorid, care being 
taken to completely surround the fistula on all sides. A grooved 



ANAI. FISTULA 151 

director or silver wire is then inserted, and the end, which has 
been brought through the anal opening, is bent so that it is ex- 
posed outside the anus. This brings the entire tract into 
view. The skin is then incised the full length of the fistula 
down to the infiltrated tissues surrounding it, but not through 
them (Fig. 90). The incisions are then carried on either side 
of the infiltrated fistulous canal in such a way as to free it en- 
tirely, and remove it unopened and threaded on the silver wire 
or director. As the incisions are carried around the fistulous 
tract, they should be brought together in a V-shaped manner 
beneath it. After the removal of the fistula, the wound should 
be loosely packed with gauze, the anodyne suppository inserted, 
and dressing applied. 

In the after-care, following both excision and incision, extreme 
care must be taken in the daily dressing of the wound to so 
arrange the drainage that it is firm enough to retard too rapid 
granulation, and yet placed so lightly as to allow the wound to 
gradually come together. Especial care must be exercised to 
keep the skin and mucous membrane from dipping in or growing 
down the sides of the incision. If granulation does not proceed 
as rapidly as it should, the gauze packing should be soaked daily 
with bovinine before applying, or pure ichthyol or balsam of 
Peru should be applied daily to the granulating surfaces. Scarlet- 
red ointment, 5 to 10 per cent, is also an excellent stimulant to un- 
healthy or sluggish granulations and should be lightly rubbed into 
the wound every third day. It is not necessary or advisable to use 
any of the antiseptic powders in the after-treatment of these 
cases. 

The bowels are not allowed to move for three days, after which 
daily movements are not contraindicated. 

Where it has been necessary to divide the external sphincter, 
either in part or in its entirety, there may be some temporary lack 
of full control of the bowel movements ; but as the wound heals, 
control is regained so that no fear need be felt on this score. The 
patient is allowed to be up and around after the first day, and 
can pursue his usual occupation with little or no discomfort. 

Ligature Ope:rations. — In some few cases, from either the 
desire of the patient that no cutting operation be done, or some 
other contraindication, one may occasionally accomplish the cure 



152 



DISEAS£:S O^ THE RECTUM 



of a simple direct fistula by means of a ligature, of linen, 
silk, or rubber. The author does not advise the use of the 




B A 

Fig-. 91. A, Technic of passing flexible silver probe, threaded with 
rubber ligature, through simple direct anal fistula. 

B. Showing method of constricting the area between fistula, anal 
mucous membrane, and skin by means of the rubber ligature drawn 
taut and fastened with a perforated shot. 



ligature in these cases, as he personally feels that they are never 
so satisfactory, and certainly not so quick in their results as a 



ANAL VISTULA 153 

clean-cut surgical operation under local anesthesia. If the 
patient must have a ligature operation, the rubber ligature as 
used by the author in his operation for rectal valvotomy is to be 
advised, as it is quicker and surer in its results than silk or 
linen. 

The ligature is applied in the following manner : A fine 
flexible probe is threaded with the material of choice, and it is 
passed through the fistula from without inward; the point pro- 
jecting in the rectum is grasped with forceps and is pulled through 
and outside of the anus. The ligature, if silk or linen, is then loose- 
ly tied so as not to constrict the parts but lightly surround them, 
and the ends are cut off. This leaves a small loop not unlike 
a seton. This is moved to and fro every day by the patient and 
in the course of three to six weeks gradually wears through, the 
fistula healing behind the ligature in the meanwhile. In some 
cases, however, this will not prove efficacious. 

Where more quick action is desired it is better to use the 
rubber ligature. It is passed through the fistula, threaded on a 
probe, in the same manner as the non-elastic ligatures, but when 
it is fastened with a perforated shot, it is put on the stretch (Fig. 
91). This causes so much pain and sufi:"ering for the first twelve 
hours that it is necessary to give the patient repeated doses 
of anodynes. After this period, however, there is comparatively 
no pain or discomfort until the ligature sloughs its way through, 
which occurs in the course of from three days to a week. The 
suffering caused by the use of this rubber ligature is far more 
intense than that experienced after one of the radical measures 
mentioned above, and the author cannot conscientiously recom- 
mend it except in those cases where other measures are refused 
by the patient. 

BLIND EXTERNAL FISTULA. 

The blind external fistula is caused by the opening of a peri- 
anal abscess on the skin surface only. It is characterized by the 
appearance, after the rupture or opening of an abscess in this 
region, of a red spot or papule from which pus is discharging. 
It is accompanied by discomfort to the patient when sitting, 
pruritus ani, or disagreeable moisture in the region; and its 
diagnosis from complete fistula is made by the method of ex- 



154 dise:ase:s of the rectum 

amination outlined above. In reality it is nothing more or less 
than a contracted abscess cavity which refuses to heal on account 
of the action of the sphincter muscle in keeping it open. 

Treatment. — The treatment consists in the incision with curet- 
ting and drainage, or excision of the entire fistulous tract. Some 
authors advise the converting of an external fistula into a com- 
plete fistula, and then operating as for complete fistula. The 
author cannot see the reason or advisability of thus converting 
a simple abscess cavity into a fistula, and would strongly deprecate 
any such methods. The author does not believe that it is ever 
necessary to divide the sphincter in order to heal a blind external 
fistula. 

BLIND INTERNAL FISTULA. 

This variety of fistula is characterized by its having an open- 
ing into the bowel only, and is caused by the rupture into the 
bowel of a perirectal abscess whose point of least resistance was 
toward the rectum. They are characterized by their insidious 
and obscure onset and often go undiagnosed for a considerable 
time. 

Symptoms. — The chief symptom is the appearance of a puru- 
lent discharge from the anus. This is accompanied by some 
smarting, burning, or itching, and a feeling of unrest or discom- 
fort in the lower rectum. If there is much involvement of the 
mucous membrane surrounding this opening, there is also a 
tendency to diarrhea. When a patient has complained of pain 
in the rectum persisting for several days, accompanied by heat, 
throbbing, and rise of temperature ; and these symptoms are 
more or less relieved just previous to the passage of a quantity 
of pus from the anus — the breaking of a submucous or perirectal 
abscess into the rectum should be suspected. The continuance 
of a purulent discharge off and on for a period of weeks and 
months means the existence of a blind internal fistula. 

Diagnosis. — With the patient in the lithotomy or lateral posi- 
tion, a roughened spot with indurated edges is felt on digital 
examination, usually posteriorly or laterally. Upon stroking 
or milking the interior of the rectum adjacent to this opening, 
a purulent discharge will be produced. Upon examination 
through the anoscope or fenestrated speculum the opening will 



ANAI. FISTULA 155 

be seen usually within the first inch from the anal margin. It 
will be dark red in color, with edges somewhat raised, and the 
extent of the fistula can be readily determined by examination 
with a soft-silver wire probe. It is well to bend the probe on 
itself in the form of a hook, so as to determine the extent of 
excavation under the mucous membrane of the bowel in the 
direction of the anus, as not infrequently blind internal abscesses, 
particularly of the submucous variety, are found with their 
largest cavity extending down toward the anus. The blind 
internal fistula is more frequently the result of a submucous ab- 
scess than of any other variety, and its channel very rarely 
penetrates the muscular coat of the rectum. 

Treatment. — With the patient either in the lithotomy or lateral 
position and the external parts washed, shaved, and sterilized, 
the sphincter ani muscle is anesthetized and dilated according to 
the technic described in Chapter X\'. Either a De A'ilbiss rectal 
speculum or the anoscope with the oblique opening is inserted so 
as to best expose the opening of the fistula. Its direction and extent 
having been determined, the tissues over the abscess and sur- 
rounding it are infiltrated with )n, per cent solution of eucain, 
or 1 per cent solution of quinin and urea hydrochlorid. A 
grooved director is then inserted, and 'the fistula is laid open 
with a long-handled scalpel, a cryptotome, or the author's angular 
rectal scissors. A pledget of absorbent cotton soaked with a 
2 per cent solution of eucain is then placed in the abscess cavity 
and allowed to remain for two or three minutes. The interior 
of the tract is lightly curetted, and a strip of sterile gauze 
inserted for drainage, one end of the gauze being carried outside 
the anus. In laying the tract open, the lower extremity should 
be opened well down to the anus, care being taken to leave no 
pockets at the lower end. In twenty-four hours the gauze is 
removed, and a cleansing enema given. The bowel should be 
allowed to move on the third day. the stools being softened by 
the administration of liquid albolene, and they should be kept 
regular each day. Ordinarily these cases will heal without any 
further attention. It is well, however, to have the patient report 
every other day for a week or so, and to make sure that the 
cavity is healing from the bottom and the granulations are healthy. 



156 DISEASES OF THE RECTUM '. 

SUBMUCOUS TRACT. 

There is a variety of submucous fistula extending usually from 
the bottom of a crypt of Morgagni, which has been called by 
Wallis a submucous tract. It consists in nothing more or less 
than either an unusually small-calibered submucous fistula, or 
a very deep inflamed crypt. It gives rise to an irritating 
purulent discharge, which is very small in amount, but which 
sometimes is responsible for the production of pruritus ani. In 
order to determine its presence, it is advisable, in those cases 
where a discharge is noted and no internal opening of a blind 
fistula can be found, to examine with a probe each of the Morgagn- 
ian crypts and determine the presence or absence of one of these 
so-called submucous tracts. If present, it can be slit up with a 
sharp-pointed bistoury or cryptotome, aftei^ anesthetizing as 
outlined above. It requires no after-treatment, other than ex- 
amination every other day for three or four days, to make sure 
that it does not heal over at the surface before it is thoroughly 
healed underneath. 

SUBMUCOUS OR MUCOCUTANEOUS FISTULA. 

Cripps describes a variety of fistula very similar to the sub- 
mucous tract, which he calls mucocutaneous fistula. It differs 
from the variety just described only from the fact that it com- 
municates with the surface through a small opening in one of 
the anal folds instead of one of the crypts of Morgagni (Fig. 
82). 

The treatment of this variety is just the same as that just 
preceding and need not be described in detail. 

INJECTION OF BISMUTH PASTE. 

The use of a mixture of bismuth subnitrate and vaselin in 
the diagnosis and treatment of fistulous tracts, sinuses, and ab- 
scess cavities, first brought out by Emil G. Beck, of Chicago, 
has opened up an interesting field in the non-operative treatment 
of anorectal fistulse. The paste recommended by Beck consists 
of bismuth subnitrate, 1 part, and vaselin, 2 parts. 

The technic is as follows : 

The patient's bowels are thoroughly irrigated, and the fistulous 



ANAI. I^ISTUI^A 157 

tract irrigated as well as possible. A cone-pointed glass syringe 
with asbestos packing around the plunger is filled with the mix- 
ture, which has previously been sterilized and allowed to cool to 
a temperature that will not irritate the patient. The point of 
the syringe is pressed well into the main opening of the fistula, 
if more than one exists, and the paste slowly injected. Should 
there be an internal opening or communication with the bowel, 
the finger of the hand not manipulating the syringe is inserted 
into the rectum to close that opening, thus preventing the paste 
entering the bowel and aiding in forcing it into all the diverticuli 
and tortuous tracts. The same precaution is observed where 
there is more than one external communicating opening. The 
syringe is not removed as soon as the tracts seem to be filled, 
but is held firmly is position with slight continuous pressure on 
the piston. A gauze dressing and T-bandage are then applied. 
From one to five injections suffice for the average case, and they 
should be given either once or twice a week. Some of the 
author's cases have required from two weeks to six months for a 
cure. While this method does not supplant the radical cure of 
fistula by operation, it should be thoroughly tried in all cases 
where operative procedures are refused or not thought advisable. 

ANAL FISTULA IN THE TUBERCULOUS PATIENT. 

The only reason that the discussion of fistula in a tuberculous 
patient is taken up among these varieties of fistula, which can be 
treated under local anesthesia, is the fact that the tuberculous 
patient is a very poor subject for general anesthesia. The ap- 
parent connection between fistula and tuberculosis is due to the 
fact of the tuberculous patient's resisting powers being away 
below par. Abscesses in the anorectal region tend to fistula 
formation frequently enough in those individuals who have a 
normal resisting power ; therefore it stands to reason that this 
should be more so in those suffering from any of the wasting 
diseases, and particularly the most common one, tuberculosis. 
The tuberculous patient's intestinal tract is constantly flooded 
with tubercle bacilli, and an abscess cavity communicating with 
the bowel forms a convenient location for them to locate and 
propagate. The old idea that the operation for tuberculous 
fistula has any bad influence on the patient's pulmonary condi- 



158 disi:ases 0^ the: rectum 

tion is absolutely untenable. As a matter of fact, the local 
symptoms and inconvenience caused by the fistula make the 
patient much more irritable and add to his already overwhelming 
burden. 

Symptoms. — The symptoms are those accompanying anal 
fistula, as described above, the constitutional symptoms of 
tuberculosis being also present. 

Diagnosis. — The only points of difference between anal fistula, 
complicated with tuberculosis, and ordinary fistula are the presence 
in the discharge of Bacillus tuberculosis, and the pink, flabby- 
looking, unhealthy granulations found around the external open- 
ing. There is also a tendency to undermining of the skin edges 
and to silkiness of the circumanal hair. 

Treatment. -^The treatment of a tuberculous fistula is the 
same as that outlined above for the diiTerent varieties of ordinary 
anal fistula, with the exception that, when the fistulous tract 
is laid open after lightly curetting, its inner surface is swabbed 
with pure lactic or glacial acetic acid. Iodoform or iodosyl 
gauze is used for packing and dressing on account of the pe- 
culiarly antagonistic effect of iodin on the tubercle bacillus. The 
patient should be encourag'ed to live an out-of-door life, and 
his general bodily nutrition and physical condition looked after 
the same as those of any other tuberculous patient. 

The injection of bismuth paste has in these cases occasionally 
proved very beneficial, and should be given a thorough trial, 
particularly in those patients in whom there exist some contrain- 
dications to surgery. 



CHAPTER X. 
HEMORRHOIDS. 

Hemorrhoids, which is the most comm.on disease of the ano- 
rectal region presenting a pathological change in the tissues, is 
also the most frequently self -treated condition affecting this 
region. We see more quack advertisements about, more nostrum 
remedies presented for, more irregular practitioners holding 
themselves out to cure hemorrhoids than any other disease (with 
the possible exception of venereal disease). In many quarters 
intelligent people, who would not think of consulting an unethical 
practitioner for any other condition, will consult the so-called 
"pile specialist" — who holds himself forth in the daily press — 
because they believe that members of the regular profession do 
not treat rectal diseases. It is perfectly astonishing to what an 
extent this belief is held ; in fact, the author is sorry to say that 
he knows of instances where members of our profession, in 
good standing, have referred cases of rectal disease to advertis- 
ing, so-called rectal specialists. 

There must be reasons for this, and the reasons are : the lack 
of instruction to the medical student on the subject of rectal 
disease, in the first place ; the paucity of such instruction when 
given as an incident in the teaching of general surgery ; the 
repugnance with which the average practitioner approaches a 
case requiring rectal examination ; the cursory character of such 
examination; the distaste of the average practitioner for local 
treatment of the anorectal region ; the inability to make a correct 
diagnosis ; and the superficial treatment given and the early dis- 
charge of the patient by the practitioner, who is anxious to get 
rid of a case, that is unpleasant for him to treat — all are re- 
sponsible for the position which the average general practitioner 
occupies today in the diagnosis and treatment of rectal diseases. 

It is the action of the profession itself which has created the 
special field of proctology — the anus and rectum being organs 
peculiar to themselves and being subject to many medical and 
surgical diseases in the same way as the eye, the ear, the nose, 

159 



160 



DISE^ASES 0^ THE RECTUM 



the genital and urinary organs; and call for just as much special 
medical as surgical care. The general surgeon knows nothing 
about, and cares less for, the medical treatment of these organs; 
and the general practitioner who is able to treat the medical 
conditions is not, as a rule, properly equipped to do so. Thus, 
the proctologist came into existence— a man who, by special study 
of this particular region of the body, is able to give special care 
of either a surgical or medical nature, and often both in the 
same case, as may be required. With his attention directed 





-,y?agK '"^^^t. 




« 


% 


p 


1 


1 




1 


1 




B 


« 




1^ 


1 








1 

1 

i 








iKmm^^^^ fjfc, . \~ 


^^5''^ 



Fig-. 92. Interno-external hemorrhoids. 

particularly to this line of work, his operative measures are 
directed largely along the lines of conservatism. He endeavors 
to save as much tissue as he can and cut as little as possible and 
by intelligent after-care to promote healing much nearer to the 
normal, as a rule, than does the man who "cuts a fistula and ties 
a pile," and allows it to go at that. 

That the average general practitioner is fully as capable of 
treating many anorectal diseases as the proctologist, if he has at 



HEMORRHOIDS 



161 



his hand a practical work outlining indicated therapeutic measures 
in a plain, simple way, goes without saying. 

The treatment of hemorrhoids in the hands of the practitioner 
has undergone vast changes since special attention has been 
directed along this line. In many ways it has been much sim- 
plified, and the results have been extremely satisfactory. 

VARIETIES. 

Hemorrhoids are tumors or swellings produced by pathologic 
changes in the veins of the anus and rectum, accompanied by 




Fig. 93. Section of interno-external pile (photo-micrograph X4). 
Upon the right-hand side of the illustration the upper half has a cover- 
ing of mucous membrane, the lower half a covering of skin; between 
these there is a sulcus, which corresponds with the pectinate line. The 
upper half is therefore internal pile; the lower, external pile. The 
structure of the interior of both portions is practically identical — loose 
areolar tissue with dilated thrombosed veins. — After Ball. 



more or less infiltration of the surrounding tissues and hyper- 
trophy of the anal skin. They are usually divided into three 
classes, according to location: external, internal, and externo- 
internal — the external being those outside the sphincteric 
region and covered by integument ; the internal being covered 
with mucous membrane, and whether situated inside the bowel 
or prolapsed outside, they are still internal hemorrhoids. An 



162 



DISE^AS^S O^ THE RE^CTUM 



internal hemorrhoid being prolapsed and remaining prolapsed 
will appear externally, but if it is covered by mucous membrane 
it is an internal hemorrhoid. The externo-internal variety (Figs. 
92, 93) is a combination of the two preceding, being covered by 
both mucous membrane and skin. The external, again, is 
divided into thrombotic, integumentary, and varicose. 

The thrombotic variety (Fig. 94, 95) usually appears suddenly; 




Fig-. 94. Acute external thrombotic hemorrhoid. 

may range in size from a pea to a large grape; is rounded, of a 
bluish or purplish hue, and extremely painful. It feels much 
larger to the patient than it really is, and is characterized by its 
sudden onset. The integumentary variety (Fig. 96) is a sac or 
pouch of thickened skin, usually the remains of an old acute 
thrombotic hemorrhoid which has undergone absorption. The 
varicose variety consists of a collection of small varicose veins 
covered by skin and situated at or outside the anal orifice. 



HEMORRHOIDS 163 

The internal variety is divided into the capillary or granular, 
and the varicose. The capillary hemorrhoid may not appear as 
a tumor at all, but simply a circumscribed reddened area which 
bleeds upon touch. Where there is an enlargement, it looks not 
unlike a raspberry. Its color is brighter than the varicose 
variety, and it bleeds more freely. The varicose internal hem- 
orrhoid is caused by a varicosity of the veins of the superior 
hemorrhoidal plexus, the varicose veins, together with the in- 
filtrated tissues surrounding them, forming rounded tumors of 
varying sizes. The internal hemorrhoids may also be divided 
into pedunculated and sessile, either of which variety may pro- 
trude through the anus. 




Fig-. 95. External thrombotic hemorrhoids. This specimen, re- 
moved from one of the author's cases, iUustrates the thrombotic nature 
of the condition. There were four, large, distinct thrombi present in this 
case, and they were removed en masse. 

CAUSES. 

A great many different causes have been assigned for hemor- 
rhoids. The principal predisposing cause is the erect position 
which man assumes, and the lack of valves in the rectal veins, 
causing the weight of the column of blood to rest on the veins 
of the lower rectum and anus. Anything which will abnormally 
increase this weight or the pressure on the vein wall will, of 
course, cause dilatation and enlargement. Constipation is an 
occasional cause of hemorrhoids. The large, hard stool, as it 



164 



DISl^ASKS 0^ THE RECTUM 



passes down through the rectum, pushing the blood ahead of it, 
and milking the veins, causes unusual pressure in the lower 
portions of the hemorrhoidal plexus at the anal canal. A more 
common cause, however, than constipation is the effort to relieve 
constipation by means of purgatives, the unnatural straining and 
the irritating liquid stools being responsible for more cases of 
hemorrhoids than constipation itself. Overeating and lack of 
exercise, or anything which causes a congestion of the portal 




Fig. 96. External cutaneous hemorrhoids. Drawn from one of the 
author's cases suffering from tertiary sypliilis. 

circulation, are important causative factors in their production. 
Occupation enters largely into their etiology. Men who are on 
their feet continually — such as policemen, letter-carriers, pedes- 
trians, railroad men, traveling men — are all peculiarly subject to 
hemorrhoids. Men are more often treated for hemorrhoids than 
women, not so much because they are more subject to hemor- 
rhoids, but because women are treated for many gynecological 
conditions, the relief of which relieves the hemorrhoids. Many 



HEMORRHOIDS 



165 



women who suffer from hemorrhoids caused by the pressure of 
the pregnant uterus wnll be spontaneously cured after dehvery. 

The most common cause, however, is, in the opinion of the 
writer, the abuse of the cathartic habit. 

SYMPTOMS. 

The three principal symptoms associated with internal hemor- 
rhoids are bleeding;, pain, and prolapse. 

Bleeding. — The bleeding is of especial interest. Many patients 




Fig. 97. Single prolapsing internal hemorrhoid. 

sultering from hemorrhoids scarcely ever, if at all, present the 
symptoms of hemorrhage. In these cases the mucous membrane 
covering the hemorrhoid is thick and is not easily ruptured, and 
the hemorrhoids may protrude without hemorrhage. Where 
bleeding is observed, it may be very slight, consisting of a few 
drops following the stool, or is simply noticed on the toilet paper 
after stool. In other cases it is very profuse, several ounces 
being lost with each stool, and some patients have become pro- 
foundly anemic from this cause alone. It might be mentioned, 



166 



DISK ASKS O^ THK RECTUM 



in passing, that it is extremely important in every case of anemia 
to inquire as to whether the patient is suffering from hemor- 
rhoids or not; as not infrequently the rectal hemorrhage will be 
found to be the cause of the trouble, and its relief will be followed 
by a prompt return of the normal amount and quality of blood. 
The author has observed in anoscopic examination typical arterial 
spurting from the midst of a hemorrhoidal mass. 

Before leaving the subject of bleeding from hemorrhoids, the 




Fig". 98. Prolapsing internal hemorrhoids at anterior and posterior 
commissure. 



author wishes to utter a word of caution about making a diag- 
nosis of hemorrhoids from the symptom of rectal hemorrhage 
alone. Many a poor unfortunate has gone to an untimely end 
because beginning malignant disease was erroneously diagnosed 
as hemorrhoids from the symptom of bleeding alone. It 
makes no difference as to the age of the patient or whether there 
is pain present or absent, the symptom of hemorrhage should 
never be taken for granted as denoting the presence of hemor- 



HEMORRHOIDS 



167 



hoids, and even where hemorrhoids are observed, no one should 
be satisfied that he has made a correct diagnosis until he has 
made a proctoscopic examination (which must include the upper 
rectum and sigmoid) and the presence of commencing malignant 
disease has been absolutely excluded (Frontispiece). 

It is not the intention of the author in this work to cite cases, 
but he could cite numerous ones seen in consultation where the 
diagnosis of malignant disease was made too late to save the pa- 
tient's life, because the patient had been allowed to go for months 




Fig-. 99. Prolapsing- internal hemorrhoids. A suitable case for 
local anesthesia. 



— being treated for hemorrhoids without ever having had a rectal 
examination made. He has also seen numerous cases of anal 
fissure diagnosed as hemorrhoids simply fromi the appearance of 
blood following stool. 

Pain. — The pain of internal hemorrhoids is somewhat charac- 
teristic, but not pathognomonic. It is more a dull aching sensa- 
tion accompanied by a feeling of fulness with or without throb- 
bing. It is seldom of an acute nature. The patient complains 
of a constant sense of weight and dragging in the rectum and 



168 



dise:ases of the rectum 



in the sacral region, and is usually more or less mentally de- 
pressed. Many patients having- hemorrhoids suffer from no 
pain whatever. 

The pain accompanying the acute thrombotic pile is sudden, 
lancinating in character, and is accompanied by the appearance of 
the tumor. The pain soon becomes of an intense, throbbing 
character, and the relief given upon the incision of the hemor- 





Fig-. lUO. Prolapsing- internal hemorrhoids. This illustrates the 
extent to which internal hemorrhoids may prolapse. This case was of 
twenty years' standing-, and unless the hemorrhoids were prolapsed 
after stool, there was nothing to distinguish the external appearance 
of the anus in this case from the normal. 



rhoid and removal of the clot has to be observed or experienced 
to be appreciated. The other varieties of external hemorrhoids 
are not accompanied by pain at all, unless inflamed, but may be 
accompanied by considerable pruritus. 

Prolapse. — In those cases of internal hemorrhoids which pro- 
lapse (Figs. 97-100), the prolapse is slight at first, gradually 



HEMORRHOIDS 



169 



increasing with time. At first the prolapse is replaced readily 
by the patient after stool, but as time goes on and the prolapse 
becomes aggravated, it will come down not only with the stool 
but when the patient is up and about and walking. It finally 
remains down and can only be replaced when the patient is lying 
down, or in the knee-shoulder position, and even when held by 
pads or retaining devices soon slips out again, when the patient 
resumes the erect posture and starts to walk. 

DIAGNOSIS. 

One would think that much space devoted to the diagnosis of 
hemorrhoids would be superfluous and that the condition almost 




Fig'. 101. Bivalve rectal speculum. This is an instrument formerly 
used for rectal examinations, but wliich, in the author's opinion, has 
absolutely no place in modern methods of examination. It may be 
used in operative work, and only when the patient is under general 
anesthesia. 



diagnoses itself, but it is because of the many unfortunate 
erroneous diagnoses of other conditions for hemorrhoids that 
the author wishes to dwell somewhat upon this point. 

In the first place, the average patient, when consulting a phy- 
sician for suspected hemorrhoidal or other rectal troubles, is 
asked to stand in front of a table (Fig. 13) and bend over on 
it for a "rectal examination," and the physician inserts his index 
finger as far as the patient will allow him, and that is all ; or he 
may take a bivalve rectal speculum (Fig. 101), and if he succeeds 
in inserting it far enough, will proceed to dilate. Usually, before 



170 dise:ase:s of th^ rectum 

he has gone very far, the patient is off the table and refuses to 
allow a repetition of the attempt, and that is about as far as 
the average rectal examination goes. 

Now a complete examination (Chapter III) of not only the 
rectum, but the lower sigmoidal cavity as well, may be accom- 
plished, practically without pain, and without any dilating specu- 
lum. Cylindrical proctoscopes of various lengths are used, and 
through them everything from the anal orifice to the lower 
sigmoidal cavity can be examined ocularly, and an absolutely 
correct view of the actual condition obtained. 

In making an examination for hemorrhoids, first ask your 
patient to lie upon the table in either the right or left Sims' 
position according to the personal preference of the examiner. 
With the finger protected by a thin-rubber finger cot, and properly 
lubricated, you proceed as follows : 

After making a careful inspection of the anus and surround- 
ing tissues, press the point of the finger against the anus, asking 
the patient to bear down as if he were trying to force the finger 
out. The palmar surface of the finger should be toward the 
posterior commissure of the anus. Allow the finger to slowly 
enter until you have entered the lower rectal cavity ; then, slowly 
turning your finger from side to side, note the conditions. As 
the finger is being withdrawn, it should be swept around slowly, 
taking note of the absence or presence of protrusions or abrasions, 
depressions, elevations — in fact, everything which does not feel 
like the normal velvety smoothness of the anal canal. An im- 
portant thing to rememiber is not to try to feel too high. These 
conditions will all be found within the first two or two and one-half 
inches, and if one does not insert the finger too far, he will be 
able to detect a great many things in this small area. One must 
remember that hemorrhoids of considerable size may not present 
any unusual feeling to the examining finger, because of the 
pressure of the finger emptying them of blood, and they are 
more or less effaced at the time. However, one can become 
sufficiently expert, so that he can detect the presence of even 
these soft elevations, and the sulci between them. 

If the hemorrhoids are accompanied by a painful fissure, one 
may not be able to insert the finger without the use of local 
anesthesia, the technic of which will be found in Chapter XV. 



HEMORRHOIDS 171 

After digital examination has been completed, an anoscope is 
introduced, the obturator withdrawn, and the patient asked to 
bear down. This will prolapse hemorrhoids into the instrument, 
where they can be examined without any difficulty, or have the 
patient assume the squatting position and "strain" the hemorrhoids 
out. Then introduce the proctoscope, and following this, the 
sigmoidoscope. In introducing the proctoscope, however, one 
must employ the knee-shoulder position. It is in this position 
only that satisfactory dilatation of the rectal cavity by pressure 
of the atmospheric air can be obtained. The folds and creases 
are all smoothed out, and every portion of the rectal lining 
mucous membrane can be explored with the eye ; the size and 
condition of the rectal valves can be determined, and the presence 
or absence of ulcers of the rectal wall as well. The sigmoido- 
scope is entered in this position or the exaggerated lithotomy or 
inverted position, and having an obturator the end of which can 
be turned at an angle, it can round the rectosigmoidal curve 
without difficulty. 

Thus it will be seen that this entire region can be successfully 
and completely examined without using an instrument which 
will dilate the sphincter any more than the base of one's index 
finger. No dilatation is required, and no pain is experienced 
by the patient. Of course, during the examination it may be 
required to swab out or irrigate the rectum, all of which can be 
readily done through the instruments mentioned. 

Differential. — In the differential diagnosis between hemor- 
rhoids and other conditions, which may simulate some of their 
symptoms, one might mention first, fissure. 

FissuRK. — Fissure of the anus, which may accompany hemor- 
rhoids, is more often found alone. The pain of fissure is almost 
diagnostic ; it is sharp, cutting, most intense during the passage 
of a stool. It remains often for several hours following stool, 
and is accompanied by more or less tenesmus and spasm of the 
sphincter muscle. The bleeding of fissure always accompanies 
or follows the stool. It may consist merely of a blood streak 
on the stool or several drops of blood following the stool, or it 
may merely be a spot or smear on the toilet paper. The presence 
of a fissure causes the patient to put off the bowel movement 
as long as possible, and when he does defecate, the hard fecal 



172 DISEASES OF THE RECTUM 

masses cause more pain and discomfort than before. Digital 
examination reveals a fissure with more or less indurated sur- 
rounding tissue, situated most often at the posterior commissure, 
or in either the right or left latero-posterior quadrants. 

Ulcer. — Ulcer of the rectum may be incorrectly diagnosed as 
hemorrhoids, on account of more or less slight hemorrhage which 
may accompany it. Ulcer, however, is usually accompanied by 
diarrhea, and ocular examination, after eliciting a history of 
blood in the stool, will settle the diagnosis at once. The same 
may be said of proctitis. An intensely congested and injected 
rectal mucous membrane may bleed on stool ; but if the con- 
scientious practitioner examines every patient who presents the 
symptom of blood in the stool, many sources of hemorrhage 
other than hemorrhoids will be detected, and the correct diagnosis 
made. 

Cancer. — Of course, the one important thing always to bear 
in mind when the symptom of hemorrhage is present is the possi- 
bility of the presence of cancer. Cancer, well advanced, may be 
found in patients who present the appearance of perfect health. 
When a patient of any age, from childhood up (just as often 
below forty as above), presents a history of rectal hemorrhage, 
which has been preceded by more or less digestive disturbance, 
including diarrhea alternating with constipation of several weeks' 
or months' standing, with considerable intestinal gas — even though 
there is no evidence of cachexia or loss of weight — one should be 
extremely suspicious of malignancy somewhere in the intestinal 
tract. If the blood is of a dark color, either of a tarry nature 
or genuine coffee-ground, the location of the cancer is higher up. 
If the blood is fresh, bright red in color, and closely follows the 
stool, and has a more or less nauseating odor accompanying it 
(an odor which is almost pathognomonic), one should examine 
very carefully for commencing cancer in the rectum or sigmoid. 
When one considers that fifty per cent of all cancers occur in 
the gastrointestinal tract, and when one realizes that sixteen per 
cent of all cancers of the digestive tract occur in the rectum or 
sigmoid, one can readily understand how important it is to 
examine every case which presents the symptoms of rectal hemor- 
rhage. 

Protrusions. — Various protrusions may be mistakenly diag- 



HAEMORRHOIDS 173 

nosed as hemorrhoids. Polypi, which may occur at any age, but 
occur more often in children, protrude with the stool. They 
are harder, more fibrous in character than hemorrhoids, and when 
replaced by the finger, go back into the rectum with more or less 
of a snap, which is somewhat characteristic of this condition. 
Anoscopic examination shows the polypus to be a small, rounded, 
hard, fibrous tumor, attached by a pedicle narrower than itself, 
its attachment being somewhat higher in the lower rectal cavity 
than that of a hemorrhoid. Enlarged rectal papillae have been 
diagnosed as connective-tissue piles. The enlarged papilla, 
however, is small, always triangular, and occasionally long drawn 
out and somewhat ribbon-shaped. It is pinkish in color and 
does not contain varicose veins. The point or tip is always 
downward, and it is attached by its base or widest portion. They 
are situated at the juncture of the anus and rectum, at the lower 
edges of the crypts of Morgagni. 

Venereal warts of large size have been incorrectly diagnosed 
as external integumentary piles, but close inspection, after ob- 
taining a history of discharge from venereal disease, should make 
the diagnosis evident. Occasionally the protrusion of an anal or 
perianal abscess may simulate an inflamed external hemorrhoid. 
However, with the finger of one hand in the rectum and the other 
hand on the protrusion, the site of the abscess cavity can be made 
out, and fluctuation often determined. The sudden onset, ac- 
companied by the intense pain, swelling, redness, and rise of 
temperature, always points to abscess formation rather than to 
hemorrhoids. 

The protrusion which is often mistaken for prolapsed hemor- 
rhoids is prolapsus ani or recti. There are three degrees of 
prolapsus : 

1. Simple eversion of the anal mucous membrane. 

2. The descent outside of the rectum of more or less of all 
coats of the rectum. 

3. The descent of the entire rectum with more or less of the 
sigmoid, which may come down to the anal orifice but not neces- 
sarily protrude. 

Prolapsed mucous membrane is dififerentiated from prolapsed 
hemorrhoids by its smooth, velvety touch, reddish color, and the 
absence of varicose veins. It is continuous with the rectal mucous 



174 DisE)ASEs 0^ the: rectum 

membrane, and a distinct sulcus can be made out between the 
anus and the protrusion in the second and third varieties. In 
the first variety, careful examination will show it to be mucous 
membrane continuous with the anal skin. Of course, in aggra- 
vated cases of prolapsed hemorrhoids more or less prolapse of 
the mucous membrane of the anus will accompany it, and the 
diagnosis is self-evident. 

TREATMENT. 

The treatment of hemorrhoids we shall divide into palliative 
and radical. 

Palliative. — The palliative treatment of hemorrhoids is, how- 
ever, not a cure, but a relief of acute symptoms for a more or 
less short period of time. When the patient presents himself 
suffering from acute prolapsed internal hemorrhoids with more 
or less strangulation by a contracted sphincter, the first thing to 
do is to reduce the prolapse. This is not always so easy as it 
seems. The contraction of a sphincter on the hemorrhoids shuts 
off the return blood supply, and the hemorrhoids swell so much 
that they cannot be replaced without anesthesia. If, however, a 
solution of adrenalin chlorid (1 :1000) or glycerin be applied by 
means of compresses, the blood-vessels will shrink to such an 
extent that reduction is often possible. Sometimes the applica- 
tion of cold or alum solutions will cause sufficient shrinkage to 
make reduction easy. Chloretone, I/2 per cent, eucain 1 to 4 
per cent may be added to these solutions to render them analgesic. 
Occasionally, applications of fluidextract of ergot will help in 
maintaining the contraction of the vessels after adrenalin has 
brought them down. An ointment containing adrenalin, 1 :1000, 
chloretone, 20 grains to the ounce in lanolin, injected into the 
anus after stool and three or four times a day, at regular in- 
tervals through a long-nozzled collapsible tube, will often assist 
in allaying an acute attack of hemorrhoids. However, all of 
these treatments are merely palliative, and the hemorrhoid upon 
the slightest irritation will enlarge, prolapse, and even strangulate 
again. 

Some patients who absolutely refuse more radical measures 
will submit to cauterization of the hemorrhoid by the thermo- 
cautery, thus causing a deposition of scar tissue on the surface 



HEMORRHOIDS 175 

of the hemorrhoid, which by its contraction somewhat lessens its 
size, and repeated appHcations of the cautery will reduce the 
hemorrhoid so that it will not be noticeable for some time. 
Occasionally such irritants as glacial acetic acid, chromic acid, 
and saturated solution of nitrate of silver have been used for a 
like purpose. The puncture of the hemorrhoidal mass in various 
places by means of the electric needle, as advocated by Kelsey, 
has been of some assistance in reducing the size of internal 
hemorrhoids, but never entirely removes them. 

Injection Treatment. — The "injection treatment," which is 
the treatment usually advocated by most of the irregulars, may 
be applied in a number of ways. The patient's rectum is cleansed 
by means of a simple enema, followed by one of the saturated 
solutions of boric acid or some other antiseptic. The hemorrhoid, 
which should be of the prolapsing variety and one that can be 
easily extruded into the anoscope, or outside, is injected down 
to its base with either a mild solution containing carbolic acid up 
to 5 or 10 per cent, if one wishes to cause a mild inflammation 
and gradual occlusion of the blood-vessels by the desposition of 
fibrous tissue, or a strong solution of carbolic acid running 
from 20 per cent to 50 per cent, when one wishes an immediate 
slough of the hemorrhoidal mass. 

When one has but one or two, or not to exceed four, prolapsing 
hemorrhoids, this method may be applicable, each hemorrhoid 
being injected at the time. In some cases two or three injections 
are necessary for each hemorrhoid at intervals of five or six 
days, but on account of the danger of injecting a blood-vessel, 
and on account of the inability to limit the slough caused by 
carbolic acid, it is rather an unsafe method ; and repeated in- 
stances of destruction of large areas of tissue, and sepsis, have 
been reported. 

A rather ingenious method of applying the injection treatment 
has been advocated by Franck, of Berlin. He employs a 50 per 
cent solution of carbolic acid in alcohol, and uses it as follows: 
The hemorrhoid is rendered tense by the application of a wire 
snare around its base; this is gradually tightened so as to cause 
the tumor to be slowly congested; the needle is then planted in 
the center of the mass, and several drops of the solution slowly 
injected. The snare is not removed until the whole mass has 



176 DISEASe:S 01^ THE RECTUM 

undergone thrombosis. Each time it is treated in a hke manner, 
and a dressing of some drying powder is apphed. In seven or 
eight days the necrotic tissue will slough off, and the granulating 
surface will be healed in three or four days. 

This long period of granulation is another objection to the ap- 
plication of the injection method. With the introduction of local 
anesthesia in the radical treatment of anorectal diseases, the field 
for the injection method has been greatly encroached upon. It 
seems to the author much more rational to remove the hemor- 
rhoid by a clean-cut surgical incision, under local anesthesia, and 
have the patient up and about on the second day, and the wound 
healed in from a week to ten days (this under local anesthesia 
in office practice) than to use the uncertain, unscientific injec- 
tion methods. Therefore, the author will confine himself in this 
chapter to a description of the various methods of operating on 
hemorrhoids under local anesthesia, as applicable in office prac- 
tice. 

Operative Treatment Under Local Anesthesia. — The technic 
of producing local anesthesia is, briefly, as follows (Chapter XV) : 

The patient, who has previously had a boric-acid enema, is 
placed on the table in the Sims' position. A large glass hypo- 
dermic syringe is filled with the solution of choice, which may be 
cjuinin and urea hydrochlorid, cocain, eucain, alypin, novocain, 
chloretone, or simple sterilized water, as the case may demand. 
Beta-eucain lactate, any strength varying from Yx to %o 
per cent, is used for anesthetizing the sphincter and is injected 
in the following manner : 

After sterilizing the parts, a point one-half inch below and 
posterior to the posterior commissure of the anus is selected. 
A drop of pure carbolic acid is used to deaden the pain which 
accompanies the introduction of the needle. With one index 
finger in the anus, hooking down the sphincter, the needle in the 
other hand is passed inward, upward, and laterally, in a V-shaped 
direction for about three fourths of an inch, going down into 
the sphincter muscle, but not through it. PVom ten drops to a 
dram of the solution is slowly injected, and the needle is retracted 
to the point of puncture, but not withdrawn; then it is pushed 
up on the other side in the same manner, keeping about one-half 
inch away from the anal aperture. 



HEMORRHOIDS 



177 



Then at least five minutes are allowed to pass to give the anes- 
thetic time to take effect. Then a vibrator, armed with a cone- 
shaped vibratode, well lubricated, is pressed against the anus. 
About three minutes of rapid vibration will dilate the sphincter 
painlessly to a sufficient caliber to allow the operation to proceed 
without difficulty. In the absence of the vibrator, one may use the 
index fingers of both hands, protected by finger cots, and by a 
gentle massage-like movement gradually accomplish the same 
object in a slightly longer period of time. 

When the sphincter is dilated, the hemorrhoid is injected from 
its base to its apex, with 1 per cent solution of quinin and urea 




Fig-. 102. Interno external hemorrhoid injected with anesthetic 
solution ready to operate. 



hydrochlorid. The particular point to remember is that dis- 
tention must be carried until the tissues are blanched and the 
hemorrhoid is in appearance not unlike a Malaga grape (Figs. 
102-104). 

It is very seldom necessary to ligate any vessels, as their re- 
traction very soon causes the hemorrhage to cease. 

The operation is then proceeded with according to the technic 
outlined below^ : 

A suppository, containing three grains of thymol iodid, two 
grains of chloretone, and five grains of quinin and urea hydro- 
chlorid, is inserted, and a dressing applied, but the patient is not 



178 



DISE:aSE:S 01^ THE RECTUM 



allowed to get up from the table for about ten minutes, then is 
asked to rise slowly and either sit down or lie down as he wishes. 
I have found that, when a patient is allowed to get up immediate- 
ly, some dizziness or faintness is complained of, and I formerly 
attributed it to the chemical anesthetics injected, until I found 
that it also occurred in those patients in whom sterile water alone 
was used as an anesthetic. 

Excision. — The hemorrhoid having a pedicle is injected at its 
base (Fig. 105) with 1 per cent solution quinin and urea hydro- 




Fig-. 103. Injection of anesthetic solution into prolapsing- hemor- 
rhoid, showing- the amount of distention necessary for anesthesia. 



chlorid — the distention carried to blanching of the tissues, the 
base transfixed with a double-threaded needle (linen suture being 
used), and the ligature double tied. The hemorrhoid is then cut 
off, leaving sufficient stump to prevent slipping of the ligature. 
Each one is treated in like manner, a suppository of the composi- 
tion mentioned above inserted, the bowels kept from moving for 
three days, and the patient allowed to be up and around after 
the first twenty- four hours. The patient is sent home usually in 
a cab (occasionally they will walk or take the car), and is ad- 



HEJMORRHOIDS 



179 



vised to lie on either one side or the other for twenty- four hours 
and then resume his occupation. It is surprising with how Httle 
discomfort they are able to get around and how quickly they re- 
cover. 

The hemorrhoid, which is sessile or non-pedunculated, is dis- 
tended in the same manner as above. The most dependent por- 
tion is grasped with the author's pile forceps (Fig. 106) or 
toothed forceps ; it is dissected up from its base with either knife 
or scissors to healthy tissue, care being taken to include in the 




Fig-. 104. Prolapsing interno-external hemorrhoid at anterior com- 
missure, anesthetized ready to operate. 



dissection the vessels which enter the hemorrhoid from above. 
The upper part of the flap is transfixed and tied ofif, as is the 
pedicle in the above variety, when the tumor is cut off with the 
scissors ; others treated in like manner, and the after-treatment 
is the same as above. It is a very rare thing for the author to have 
hemorrhage severe enough to require ligation of the vessels. 
Where there is more or less oozing, a piece of rubber-tubing, 
about four inches long and surrounded by gauze, is inserted, and 
the pressure of the gauze against the raw surface very soon 



180 



DISE^ASES OF THE RECTUM 



checks oozing. This is removed in anywhere from one to twenty- 
four .hours. 

Author's Bloodless Operation. — A somewhat simple method 
is the author's technic for the removal of certain forms of internal 
hemorrhoids without the profuse hemorrhage with which this 
operation is usually associated in the minds of most medical prac- 
titioners. From the observation that most patients suffering 
from hemorrhoids of the internal varietv are more or less anemic 




Fig-. 105. 
hemorrhoids. 



Method of injecting prolapsing- pedunculated internal 



from the continued and constant loss of blood, as a result of their 
hemorrhoidal trouble, he decided to use a technic that would 
minimize operative hemorrhage and conserve the patient's blood 
supply. With this aim in view, he has developed and has been 
using a very simple technic which is presented below : 

It is applicable under local as well as general anesthesia, and 
therefore can be used in those weak, run-down patients suffering 
from any of the wasting diseases, in whom the use of a general 



HEMORRHOIDS 



181 



anesthetic would be inadvisable, if not positively dangerous. The 
method is applicable to any variety of internal hemorrhoids, and 
particularly to the pedunculated and prolapsing varieties. Interno- 
external hemorrhoids can also be treated by this method. Very 
few instruments are required, and in most cases dilatation of the 
sphincters is not required. The technic under general anesthesia 
is much the same as under local anesthesia, and inasmuch as local 
anesthesia is a good deal safer and fully as satisfactory as gen- 
eral anesthesia for this work, the author will describe the opera- 
tion as performed by him under local anesthesia. 

The instruments required are a rectal retractor (Fig. 107) or 
Sims' speculum; the author's blunt-pointed ligature carrier (Fig. 
108), the author's pile forceps (Fig. 106), scalpel, sharp-pointed 
scissors curved on the flat (Fig. 62), aseptic hypodermic syringe 
with sharp needle, and chromic catgut. The patient is given one- 




Fh 



lOG. Author's hemorrhoidal forceps. 



fourth grain of morphin about twenty minutes before the opera- 
tion is performed ; the bowels are washed out with a soapsuds 
enema, followed by a boracic acid enema. He is then placed on 
the operating-table in the Sims' lateral position ; the skin around 
the anus is scrubbed, shaved, and sterilized. The sphincters are 
then anesthetized by the injection of 20 to 30 minims of ^ per 
cent beta-eucain lactate solution, which has been sterilized by 
boiling, according to the technic described above. 

When dilatation has been accomplished, the most dependent 
hemorrhoid is injected with 1 per cent solution of quinin and 
urea hydrochlorid, and the distention carried until the tissues are 
blanched. Anesthesia is then complete. The lower extremity of 
the hemorrhoid is then grapsed with the author's pile forceps 
(Fig. 109) and pulled down so that it is on the stretch. The 
blunt-pointed ligature carrier, threaded with No. 2 catgut, is 
passed in through the mucous membrane on one side, down to 



182 DISEJASKS 01^ THE RECTUM 

the base of the hemorrhoid and around to the opposite side, in 
such a manner as to include the upper half of the mucous mem- 
brane covering the pile, and the blood-vessels underneath, but not 
encircling the entire hemorrhoid as in ligating a pedicle (Fig. 
IIOA). This ligature should be placed just at or above the junc- 




Fig. 107. Rectal retractor modified from Sims' speculum. 




Fig-. 108. Author's blunt-pointed ligature carrier. 

ture of the pile and the healthy mucous membrane of the rectum. 
It is then firmly tied (Fig. HOB), and it will be found that the 
blood supply of the pile has been included in the ligature and 
shut off (Fig. 111). The piles at either side are treated in like 
manner and lastly the upper ones. A suppository containing: 



he:morrhoids 



183 



Chloretone gr. ij 

Thymolis iodidi gr. ij 

Quininse hydrochloridi carbamidati gr. x 

is inserted, the patient keeping in the recumbent position for ten 
minutes, and then allowed to rise from the table and go to his 
bed. There will be considerable sw^elling during the first twenty- 
four hours, but this, with its accompanying pain, can be relieved 
by the application of hourly compresses soaked in the following 
solution : 




Fig-. 109. Internal hemorrhoid anesthetized, ready to remove in 
grasp of author's hemorrhoidal forceps. 

I^ Adrenalin chlorid (1:1000) Sss 

Chloretone gr. xxx 

Glycerini ^iv 

Aquse §iv 

This swelling subsides in from two to four days, and the pile 
gradually shrinks until at the end of four weeks there is nothing 
left but a little hard "nub" of connective tissue, which can then 
be removed painlessly with the scissors. This, which is the sim- 
plest form of technic, is applicable in those desperate cases of 
anemia wher^ the continual loss of blood from the hemorrhoids 



184 



disease:s 0^ the: re:ctum 



is greater than the patient's blood production. It can be done in 
ten or fifteen minutes and involves the least expenditure of nerve 
endurance and suffering of the patient. In cases where the neces- 
sity for haste is not quite so imperative, I use the following modi- 
fication of the technic : 

After the hemorrhoid is anesthetized as above, and the ligature 
applied in the same manner, the pile is grasped in the author's 




Fig-. 110. Technic of author's bloodless operation for internal 
hemorrhoids. 

A. Method of inserting ligature-carrier, threaded with catgut. 

B. Showing ligature tied, thus constricting the blood-vessels sup- 
plying the hemorrhoid. 

C. Removal of the hemorrhoidal mass without sacrificing the 
mucous membrane. 



pile forceps, and an incision made in its longitudinal axis, and 
extending down to its distal extremity ; then, with the curved 
scissors, the blood-vessels and connective tissue which make up 
the body of the pile are dissected out en masse (Fig. HOC) and 
cut off about one quarter of an inch from the ligature. The 
wound is left open to heal by granulation, which it does in a very 
few days. This dispenses with the hemorrhoid at once and does 



HEMORRHOIDS 



185 



away with the swelling, pain, and discomfort which necessarily 
follow the preceding technic. 

In cases where we have pedunculated or prolapsing hemor- 
rhoids, it is not necessary to dilate the sphincter or use the 
speculum. Following an enema, the patient is asked to strain 
while in the squatting position or lying on his side, while the 
operator is everting and pressing back the sphincter muscles by 
pressure just outside the outer margins of the external sphinc- 
ters. The pile which is prolapsed by this method is injected with 




Fig-. 111. Same case as Fig-. 99. 
rhoids controlled by four ligatures. 



The blood supply of all hemor 



1 per cent solution of quinin and urea hydrochlorid. Its pedicle 
is transfixed with the blunt ligature carrier double threaded with 
catgut, and tied off in two sections. The pile is then cut away 
one quarter of an inch from the ligature, and the stump cauterized 
w^ith 95 per cent carbolic acid. The other pedunculated hemor- 
rhoids are treated in like manner, the analgesic suppository in- 
serted, and the operation is completed. 

The after-care is very simple, the bowels being confined for 
three days. A dram of compound licorice powder at night, fol- 



186 DISEASES O^ THE RECTUM 

lowed by a six to ten-ounce oil enema in the morning, will pro- 
duce an easy and satisfactory movement at the end of that time. 
A tablespoonful of liquid albolene, daily before retiring, will keep 
the bowels in good order, and daily soft movements will follow. 
The only dressing required is a powder, such as compound stea- 
rate of zinc, which should be applied sufficiently often to keep 
the parts protected. Some of the many advantages of this method 
are as follows: 

1. The technic is simplicity itself. 

2. It is applicable under local anesthesia. 

3. It takes a shorter time than any other method which suc- 
cessfully disposes of the hemorrhoid. 

4. It is surer, safer, and quicker than the "injection method," 
and is applicable in every case where the injection method can 
be used, as well as in other varieties of hemorrhoids where the 
injection is contraindicated. 

5. It should be the method of choice in all patients suffering 
from anemia, tuberculosis, hemophilia, and in pregnancy — be- 
cause of all the foregoing reasons, and the fact that it does not 
involve the loss of blood. The principle of tying before cutting 
reduces the waste of blood to a minimum, and makes for rapid 
convalescence. 

6. There being no confinement in bed after the first twenty- 
four hours, the patient may be up and about, going out of doors, 
getting fresh air, sunlight, and exercise, which are nature's best 
curative agents in convalescence after any operation or disease, 
and of the greatest value to patients suffering from any of the 
wasting diseases mentioned above. 

Submucous Excision. — In the sessile variety, another way of 
treating these is simply to make an incision in the longitudinal 
axis of the bowel through the center of the mass, and then by the 
use of the author's angular rectal scissors (Fig. 55) to macerate 
and destroy the blood-vessels, beneath the mucous membrane on 
either side of the incision. The blood supply being destroyed 
and the macerated tissue cleaned out with a curette, the wound 
is allowed to heal without suture, and usually does in four or five 
days. Of course, this method is accomplished by some hemor- 
rhage, but never severe enough, however, to require ligature. 
The after-treatment is the same as in the other varieties. 



HEMORRHOIDS 187 

CivAMP AND Cautkry Opi:ration.- — The clamp and cautery 
operation is not applicable, of course, under local anesthesia, and 
I mention it merely to condemn it. I do not believe that the use 
of a red-hot iron in a cavity lined with mucous membrane is 
rational, and while I am aware that many surgeons have used it 
with many successful results, I have seen strictures following its 
use which were caused by the overgrowth of scar tissue — which 
is more prone to follow a burn than any other form of wound. 
A clean-cut surgical incision, to my mind, is more rational and is 
not followed by the extensive sloughing or the extensive cicatrix. 
Crushing the hemorrhoid with the angiotribe has also been used 
by some operators, and offers the objection that it destroys too 
much mucous membrane and is followed by a more or less chronic 
granulating surface taking weeks to heal. 

WhitkhEad Operation. — The Whitehead operation is, in the 
author's opinion, very seldom, if ever, indicated. 

Othe:r Methods. — Other methods of disposing of large re- 
dundant hemorrhoidal masses by means of elliptical flaps, longi- 
tudinal incisions, and plastic work are used to obviate the neces- 
sity of doing any operation, which is almost certain to be fol- 
lowed by sepsis, retraction of flaps, and subsequent cicatricial 
contraction; and the author has yet to see a case of hemorrhoids 
accompanied by prolapse so severe that he has not been able to 
remedy it without sacrificing the normal contour of the anus. 

Removal oe Acute Thrombotic Hemorrhoids. — The acute 
thrombotic variety (Fig. 94) is peculiarly amenable to treatment 
under local anesthesia. On account of its sudden onset and the 
acute suffering which it produces, the patient will present himself 
for treatment within a few hours after its onset. Examination 
in the lateral position shows a rounded, bluish or purple tumor, 
varying in size from that of a pea to a large grape, located just 
at the anal margin, usually on one side. It usually occurs singly. 
After the usual preparation, the hemorrhoid is injected from its 
outermost aspect with 10 or 12 drops of ^ per cent solution of 
eucain lactate, or 1 per cent quinin and urea hydrochlorid — the 
injection being carried just underneath the skin or mucous mem- 
brane, and not down into the pile. After allowing five minutes 
for the anesthetic to take effect, an incision is made through the 
skin and down to the clot, parallel to the long axis of the anus 



188 dise:ases o^ the rectum 

and extending for about one quarter of an inch into the skin 
beyond the tumor. The tissues around the tumor and below it 
are injected with 1 per cent solution of quinin and urea hydro- 
chlorid, when it is dissected out by means of a small-toothed 
forceps and the curved scissors. After the clot (Fig. 95) is re- 
moved, look carefully into the wound to see whether a second 
clot has formed below, and if so, it must be removed at the same 
time. The edges of the wound are trimmed back in an elliptical 
manner, so as to leave a gaping wound, which will heal by granu- 
lation from the bottom, without any possibility of the edges of 
the wound turning in and retarding its healing. A one-half-inch 
strip of tape or gauze is lightly inserted into the wound, and a 
sterile dressing applied. This gauze is removed in twenty-four 
hours, when it will not be found necessary, as a general rule, to 
redress the wound. It should be seen and dressed daily, and 
some mild antiseptic powder applied, such as thymol iodid, boric 
acid, boro-chloretone, stearate of zinc, or acetanilid. The patient, 
after this operation, experiences a keen sense of relief from the 
start from the relief of the tension caused by the thrombotic mass. 
REMOVAL 01^ External Integumentary Hemorrhoids. — The 
removal of external hemorrhoids of the integumentary (Fig. 
60) variety is very easily accomplished under local anesthesia. 
After the parts are cleansed, shaved, and sterilized, with the pa- 
tient placed in the left lateral or lithotomy position, the most de- 
pendent pile is selected, the point of puncture touched with a 
drop of pure carbolic acid or sprayed with ethyl chlorid until the 
tissues are blanched, when the spray is removed, and as soon as 
it has regained its natural color the injection is made. As 
in all operations involving the skin, the first injection should be 
of y^ per cent solution of eucain lactate, care being taken to 
inject the first ten or fifteen drops just underneath the skin along 
the line of the proposed incision so as to form a wheal or welt. 
An incision is then made on a line radiating at right angles from 
the anal orifice to the distal extremity of the tumor ; then the sub- 
cutaneous tissues are infiltrated with ^o P^^ cent eucain solu- 
tion, or 1 per cent solution of quinin and urea hydrochlorid, or 
sterile water. The hemorrhoidal mass is then seized with the 
author's hemorrhoidal forceps and removed with a fiat pair of 
scissors. The skin edges are trimmed back on either side in the 



he:morrhoids 



189 



shape of an ellipse, so as to include all of the redundant tissue 
which forms the covering of the pile. One must be cautious 
about cutting away too much skin. The distention with the 
anesthetic solution somewhat distorts and distends the skin, 
and the infiltration extends beyond the part to be removed, mak- 
ing it appear much larger and extensive than it is in reality (Fig. 
112). It is a wise plan, therefore, to carefully mark out, before 
proceeding to operate, the extent of the proposed incision by 
means of a small swab moistened with tincture of iodin. Each 




Fig-. 112. Distention of external hemorrhoids with sterile water. 
This photograph is taken from the same case as Fig. 60, and comparison 
of the two will be of interest. 



hemorrhoid is treated in like manner, working from below up- 
ward, and the wound is allowed to heal by granulation. There is 
no objection to putting a couple of silkworm stitches in each 
wound, if desired; but the author has found healing fully as sat- 
isfactory without stitching, and the time of operation is materially 
lessened, which is an important factor in all work under local 
anesthesia. 

The after-care is similar to that outlined in the treatment of 
acute thrombotic hemorrhoids. The healing following operation 



190 DIS^ASE^S 0^ THE RKCTUM 

for external hemorrhoids should be complete in a week or ten 
days. 

During the healing process, the patient should be required to 
use an inflated air cushion, or pillow, when sitting, and to lie 
upon either side rather than upon the back. As has been stated 
above in the treatment of internal hemorrhoids, it is wise to put 
the patient upon a light diet, consisting of meat-broths, and 
strained vegetable soups, with the addition of eggs and gelatins, 
for the first three or four days. The bowels should be confined 
until the third day, when by means of a dram or two of licorice 
powder given the night before, followed in the morning by a 
ten-ounce oil enema, the bowels should be moved. The move- 
ments thereafter should be kept soft by the administration of 
half-ounce doses of white refined petroleum oil (liquid albolene) 
daily at bedtime, and the diet gradually increased. After the 
first movement, daily evacuation of the bowels should be secured. 

Where, on account of the number and redundancy of external 
hemorrhoids, the operation for their removal under local anes- 
thesia would be too extensive or involve too much time if at- 
tempted at one sitting, the work may be divided : half being taken 
care of at one time, and the other half after an interval of two 
or more weeks. The author would not advise the removal of more 
than three or four external hemorrhoids at one operation. It is 
very rare, however, to find more than this number as a general 
rule. 



CHAPTER XL 

RECTAL POLYPI— HYPERTROPHIED ANAL 
PAPILLA— CRYPTITIS. 

POLYPUS. 

A polypus is a non-malignant tumor, whose chief characteristic 
is its attachment to the rectal wall by a pedicle, which is always 
narrower than the tumor (Fig. 113). It occurs more often in 
children than in adults. Polypi may be found singly or in such 
large numbers as to entirely fill the rectal cavity, and will be found 
complicating anal fissure, hemorrhoids, prolapse, and other rectal 
diseases. 

The usual location of a polypus is in the lower end of the rectal 
canal from one to two inches from the anal opening. Rarely 
cases have been seen in which the polypus was found attached 
by a pedicle four or five inches long as high as the rectosigmoidal 
juncture. 

The types of polypi most commonly seen are either the soft 
myxomatous or adenomatous variety, or the hard fibroid poly- 
pus. In appearance, the soft granular polypus resembles a rasp- 
berry, and bleeds readily at the touch. The fibroid variety is 
hard, rounded, and lighter in color than the normal rectal mucous 
membrane. 

Symptoms. — The usual symptoms, outside of the appearance 
of the polypus itself, are the passage of blood and mucus, and 
straining efiforts after stool — the patient complaining of a feeling, 
as if more fecal matter were in the rectum, but it was impossible 
to evacuate it. 

Diagnosis. — The diagnosis is very simple, as they are often 
discovered protruding from the anus. A peculiar characteristic 
of polypi is the snapping sensation which they give to the finger 
as they are returned to the rectum. On making a digital examina- 
tion, with the patient in the lateral position, one should insert 
the finger as high as possible, and then sweep it from side to 
side, completely encircling the rectum on its withdrawal, when the 

191 



192 



DISKASES 01^ THE RECTUM 



polypi will be discovered, usually just above the internal sphincter. 
As the finger is withdrawn, the polypi can often be brought with 
it, outside the sphincter. By means of proctoscopic examina- 
tion, polypi situated higher in the rectum may be discovered. 

Treatment. — In the treatment of polypi, local anesthesia is 
often not necessary. They can be snared off with ease through the 
anoscope or proctoscope with little or no pain. Where a poly- 
pus is situated low, so that it can be extruded through the anus, 




Fig-. 113. Rectal polypus. 



the pedicle may be infiltrated with %o P^i" cent solution of 
eucain, or 1 per cent quinin and urea hydrochlorid, transfixed with 
a double-threaded needle, and the pedicle tied off in two sec- 
tions with a double ligature. The polypus is then snipped off 
with scissors, leaving as little stump as is possible. It is prac- 
tically never necessary to anesthetize the sphincter, and no after- 
treatment is required. 



RECTAI, POLYPI — ANx\L PAPII^L^^ — CRYPTITIS 193 

HYPERTROPHY OF THE ANAL PAPILLA. 

In devoting some space to the anal papillae, the author has done 
so with the view of bringing before the profession a condition 
which is practically never recognized by the general practitioner, 
and usually overlooked by the general surgeon, who includes rec- 
tal surgery as an incident in his practice. It is one of the many 
minor conditions which originate in the anal canal, which, while 
never causing such serious symptoms as to endanger health or 
life, or causing such great suffering as to incapacitate the patient 
from his daily occupation, nevertheless, is of no small interest 
to the medical practitioner because of the amount of discomfort 
it causes. 

This may only amount to a feeling of uneasiness, but the hy- 
pertrophied anal papilla is often responsible for symptoms ridicu- 
lously out of proportion to the size and severity of the lesion. 

Many irregular practitioners, who hold*^ themselves out as 
''rectal specialists,"' have made great capital out of the anal 
papillae and have attributed^ to them the causation of nearly every 
disease in the calendar. As a result, many of the profession have 
gone to the other extreme, and have completely ignored the ex- 
istence of what has been proved to be definite diseased condi- 
tions of definite anatomical entities. 

When a patient complaining of indefinite rectal or anal S3'mp- 
toms consults his physician, too often he is dismissed with some 
proprietary ointment, without any effort being made to locate the 
cause of the trouble. The special study of the rectum, with its 
allied organs, the anus and the sigmoid, has brought to view 
many interesting conditions which have been overlooked in the 
past, and it is with the view of clearing up some of the obscure 
and indefinable symptoms which originate in the region of the 
anus, that the author is devoting this space to hypertrophy of the 
anal papillae. 

It is in the anal canal, where most of the pathological conditions 
which cause pain and suffering, and reflexes without number orig- 
inate. Nature has been unusually lavish in her sensory nerve 
supply to these organs, and lesions in this region produce referred 
disturbances in many other and remote organs. When one con- 
siders that the anal canal measures from two-thirds to an inch 



194 



DISEASES 01? THE RECTUM 



and a quarter in length and its circumference about one and one- 
quarter inches in the contracted condition, one can readily see 
that it is not a large area to examine and study, and diseased con- 
ditions in this region should not be difficult to discover, diagnose, 
and remedy. 




Fig. 114. Sectional view of the anal canal showing hypertrophied 
anal papillae and crypts of Morgagni. 

C. Opening of crypts of Morgagni. 
P. Hypertrophied papillae. 
N. Normal papilla. 

The anus is peculiarly susceptible to injury and disease. First, 
because its lining membrane, being neither skin with its tough 
resisting power nor mucous membrane with its generous vascular 
supply, but a sort of transitional tissue, neither one nor the other, 
is easily injured. Secondly, any lesion occurring in this region 



RE:CTAL rOLYPI — ANAL PAPILLA — CRYPTITIS 



195 



has a small chance of recovery because of its meager blood sup- 
ply, and its constantly changing position, and because of trauma 
and infection from the contents of the bowel which are constant- 
ly passing over it. 

In order to understand more intelligently the condition under 
discussion, it might be well to say a few words about the normal 
anatomy of the anal papillae (Fig. 113). These papillae occur as 
an irregular line of small saw-tooth-like projections encircling 




Fig-. 115. Hyperfrophied anal papillae. This well shows the ap- 
pearance of the anal papilla when the anal margin is put upon the 
stretch by strong- traction. 



the point of the juncture of the anus with the rectum, sometimes 
called the line a dent at a. These papillae, varying in number from 
five to a dozen, are usually situated at the edges of the semi- 
lunar anal valves which guard the crypts of Morgagni. Andrews 
considers these papilla the normal tactile organs of the rectum 
and endowed with a special rectal sense. They have an abundant 
nerve supply, which accounts for the many reflex disturbances 
which originate when they are diseased. 



196 DISEASES 01? THE RECTUM 

Examination and Diagnosis. — In making a digital examina- 
tion, unless one is rather expert, these papillae are not always 
evident to the touch, but are apt to be overlooked unless an ocular 
inspection is made. When diseased, these papillae may vary in 
size from a quarter of an inch in length, by the same breadth at 
the base, to an inch and a quarter or an inch and a half in the 
longest diameter (Fig. 114). They are composed largely of an 
overgrowth of normal tissue. Often, by everting the anus, the 
tips, and often all of the hypertrophied papillae themselves, can 
be brought into view (Fig. 115). They are of a pinkish color, 
slightly paler than the normal mucous membrane of the rectum. 

A distinguishing point between hypertrophied papillae and polypi 
is the fact that the hypertrophied papilla is always wider at its 
base than the apex, while the polypus is always larger than the 
pedicle by which it is attached. The polypus is usually rounded 
or oval in shape, while the papilla is more or less triangular, or 
ribbon-shaped. Enlarged papillae have been incorrectly designated 
as connective-tissue piles. They never show the characteristic 
varicose appearance of the internal hemorrhoid and are attached 
at the anorectal line. 

Containing some erectile tissue, on examination through the 
anoscope they will often be seen to stand out at right angles from 
the mucous membrane, giving the anal canal at this point a 
fringed appearance (Fig. 116). i\Iany a surgeon, when he can 
discover no pathological lesion but finds a tight sphincter, over- 
looks what he may call ''little tags of the mucous membrane." 
These are very frequently the cause of the tight sphincter, for 
let it be said here that no sphincter is abnormally tight unless 
there is some pathological lesion causing it, and a simple divul- 
sion of the sphincter will not relieve the symptoms, as many a 
surgeon and patient have found to their chagrin and disappoint- 
ment. 

Symptoms. — These papillae, being situated on the edges of the 
semilunar valves, are pushed and dragged downward during the 
passage of feces, which are more firm and harsh than normal. 
At each bowel movement there is a further pull and drag on the 
papilla, which is gradually stretched and hypertrophied. After 
it has become sufficiently hypertrophied, it will not retract at 
once after a movement, but will remain in the grasp of the in- 



RECTAL POI.YPI — ANAL PAPILLA — CRYPTITIS 197 

ternal sphincter, causing the sphincter to contract. This contrac- 
tion gradually becomes more tonic, and eventually we have what 
has been called the "tight contracted sphincter." This gives 
rise to one of the most characteristic symptoms of hypertrophied 
papillae — that of an unsatisfied feeling after stool — a feeling as 
if some particle of fecal matter were still in the grasp of the 
sphincter and could not be expelled, also a feeling of irritation 
and uneasiness, short of itching. As one patient described it to me, 
''It felt like the bite of some small animal," and he was sure that 




Fig-. 116. Proctoscopic view of an ag-gravated case of hypertrophied 
anal papillee. 

he had a tapeworm, because he "could feel it nibbing at the anus." 
Another stated that it felt like a bur, held in the grasp of the 
sphincter. This feeling can be immediately relieved by the in- 
sertion of the lubricated finger and pushing up and replacing the 
enlarged papillae which will be found in the grasp of the in- 
ternal sphincter. If they are left to themselves, it will often take 
from fifteen minutes to an hour and a half for them to gradually 
retract, when symptoms will entirely disappear. They cause 
spasm of the sphincter, and the constantly repeated spasms bring 



198 DISEASES O^ THE RECTUM 

on a hypertrophy of the circular muscular fibers, forming the 
sphincter muscles, and the hypertrophied sphincter is the so- 
called ''tight sphincter." 

Another symptom which the hypertrophied papillae cause is 
so-called neuralgia of the rectum, being transferred and trans- 
mitted pains from the pressure on the nerve-endings of the 
papillae. One of the most common symptoms, however, for 
which hypertrophied papillae are responsible is pruritus ani. I 
do not wish to be misunderstood as saying that hypertrophied 
papillae are the commonest cause of pruritus ani, because the 
causes are legion — but they are a common and probably the most 
frequently overlooked cause. 

CRYPTITIS. 

It will be remembered that each papilla is found at the edge 
of a semilunar valve, which semilunar valve is the outer bound- 
ary of one of the crypts of Morgagni, also known as rectal 
pockets or mucous crypts. These crypts, whose function is not 
thoroughly understood as yet, become clogged with fecal matter, 
which on account of the shape of the crypt or sac is not readily 
expelled. The enlarged anal papilla overlying the crypt assists 
in preventing its escape. The decomposition of this fecal matter 
or retained secretion, and the consequent irritation of the crypt, 
set up an inflammation or cryptitis, which may frequently go on 
to pus formation. The accumulated discharge originating here 
overflow.s from the crypt, and as it runs down the mucous mem- 
brane of the anus, sets up an irritation, which is made manifest 
by itching or pruritus, and the moisture complained of by many 
patients suffering from pruritus will be found to originate from 
this source. 

The feeling of uneasiness following stool, of which some pa- 
tients complain, is unlike that produced by any other condition. It 
has been described to me by one patient as a feeling as if he 
had thorns or pine needles in the anus — a sort of prickling sen- 
sation — not painful, but very uncomfortable ; and he would find 
himself constantly shifting from side to side as he sat in a 
chair. Occasionally the shifting would relieve him, when as- 
sisted by some pressure on the anus, thus releasing the papillae 
from the grasp of the sphincter. 



RKCTAIv POIvYPI — ANAL PAPILLAE — CRYPTlTiS 199 

It is not only the extremely long papillae for which we must 
look to cause these symptoms, as those which are only half an 
inch in length, the tips of which are just engaged in the sphincter, 
are sufficiently enlarged to cause symptoms. 

Another condition which has been found to follow the hyper- 
trophy of an anal papilla is anal fissure. This is caused, as has 
been demonstrated by Wallis, of St. Mark's Hospital, London, 
by sufficient pressure during stool to tear the papilla downward 
from the edges of the crypt, and as succeeding stools continue 
the tearing process, the edge of the crypt is brought down to 
the outside of the anus, leaving in its wake a raw, ulcerated 
furrow (Fig. 70), which is split open further by each stool, and 
gives rise to the many severe and intolerable symptoms attending 
anal fissure. 

Treatment. — The treatment of this condition is extremely sim- 
ple and consists in the removal of the papillae when they are en- 
larged and the opening and cauterization of the crypts when in- 
flamed or infected. Both conditions are present together so often 
that their treatment will be considered together as well. The re- 
moval of papillae is accomplished in the following manner: 

The anoscope, or fenestrated speculum, is inserted, with the 
opening directed toward the lowest papilla to be removed. The 
papilla is injected at its base with %o P^^ cent solution of 
eucain or 1 per cent of quinin and urea hydrochlorid, and dis- 
tended to whiteness. After waiting ten minutes, the papilla is 
removed as close to its base as possible by means of the snare, 
excision, or crushing. It is never necessary to anesthetize the 
sphincter, and oftentimes the anoscope or speculum is not re- 
quired. By eversion of the anus (Fig. 115), the papilla may be 
brought into view and anesthetized and removed while thus ex- 
posed. 

No dressing is required, the hemorrhage, which is slight, soon 
ceases, and no after-care is necessary, other than that employed 
following the operation for simple fissure. 

When one of the Morgagnian crypts is inflamed, the area sur- 
rounding the crypt, including the papilla, should be injected and 
distended with the %o pei* cent solution of eucain, and a V- 
shaped incision made from above — the base being at the mouth of 
the crypt and the apex one-half inch below its center. This in- 



200 DISEASES OF THE RECTUM 

cision should be deep enough to open well the crypt. The flap, 
which includes the papilla, is removed, and its base cauterized 
with a saturated solution of silver nitrate. A suppository contain- 
ing two grains each of chloretone and thymol iodid and five 
grains of quinin and urea hydrochlorid is then inserted. Where 
more than one crypt is involved, the same technic is employed for 
all, the lowermost crypt being operated first, and the others in- 
jected just before operating. The after-care is the same as 
has been described for hypertrophied papillae. 



CHAPTER XII. 
PROCTITIS AND SIGMOIDITIS. 
This consists of a catarrhal inflammation, either acute or 
chronic, affecting the mucous membrane lining of the rectum, 
sigmoid flexure, or entire colon. There are many varieties of in- 
flammation affecting the rectum and sigmoid due to the invasion 
by the micro-organisms of gonorrhea, syphilis, diphtheria, ery- 
sipelas, and dysentery. With the exception of the last-named 
variety, the inflammation caused by the micro-organisms of dysen- 
tery, the other varieties accompany or are caused by diseases af- 
fecting other organs and occur as a complication, and will not 
be described in this chapter. Amebic dysentery will be discussed 
fully in a separate chapter. The author, therefore, will limit 
himself to discussion of simple catarrhal proctitis and sigmoiditis, 
acute and chronic. 

ACUTE PROCTITIS AND SIGMOIDITIS. 

Etiology. — This disease occurs at all ages, children being af- 
fected as frequently as adults. Among the predisposing and 
causative factors are sudden changes in climate, weather, or mode 
of living; the ingestion of highly seasoned foods, condiments; 
and excesses in the use of alcohol or tobacco. Constipation is 
occasionally a causative factor, but the presence in the rectum of 
intestinal parasites, impacted feces, or foreign bodies, as well as 
infection of the rectum, from unclean enema tips or examining 
instruments, are more often responsible for its onset. Patients 
suffering from ''rheumatism" and gout or those who are peculiarly 
susceptible to sudden chilling of the skin surface are particularly 
liable to attacks of acute catarrhal proctitis. Acute indigestion, 
with its attendant fermentation of food products in the intestinal 
tract, and ptomaine poisoning are very prolific sources, and inflam- 
mation by extension from any acute pelvic disorder is not uncom- 
mon. The use of drastic cathartics is also an etiologic factor 
of no small importance, and the ingestion of many food articles, 
which in some individuals causes urticaria of the skin surfaces, 
will often be responsible for an attack of acute catarrhal proctitis. 

201 



202 diskase:s 01^ the: re:ctum 

Symptoms. — Its onset is attended oftentimes by a chill, slight 
rise of temperature, and a sense of uneasiness in the rectum and 
lower abdomen ; oftentimes accompanied by backache, partic- 
ularly over the sacral region, and occasionally shooting pains 
down the limbs. This is followed in a few hours by a sense of 
fulness and heat in the rectum, with a constantly increasing de- 
sire for stool. Disturbances of the bladder are noted, particu- 
larly a desire to urinate frequently and a burning sensation while 
doing so. The patient is most comfortable lying on his side. 
The movements become soft, and frequent evacuations occur. 
At first the movements are those of ordinary diarrhea ; after the 
first day or so, the movements consist more largely of feces mixed 
with mucus and sometimes tinged with blood. If the disease pro- 
gresses and ulceration occurs, the movements contain blood and 
pus, and a mucopurulent discharge will be noted at the anal 
orifice between movements. In children, this condition fre- 
quently brings about prolapse of the rectum, and occasionally 
also in adults. 

Diagnosis. — With the history of an onset, such as has been 
given above, examination of the rectal cavity is indicated. With 
the patient in the knee-shoulder position the proctoscope should 
be inserted, and the rectum inflated. If the insertion of the 
proctoscope is accompanied by considerable pain, as it will be in 
many cases suffering from proctitis, the sphincters should be first 
anesthetized according to the technic outlined in Chapter XV. 
The appearance of the mucous membrane of the rectum is some- 
what characteristic. Upon ocular examination, the rectal mucous 
membrane is bright red in color, its appearance being not unlike 
that of the inflamed conjunctiva, the difference being that the 
rectal mucous membrane will be more of a brick-red color, 
and the mucous membrane appears somewhat velvety and edema- 
tous. An increased quantity of stringy, yellowish mucus will be 
noted. The blood-vessels of the rectal wall, and particularly on 
the valves of Houston, will be found deeply injected and clearly 
outlined, standing out distinctly from the red mucous membrane. 

Treatment. — The treatment of acute catarrhal proctitis is 
dietetic, systemic, and local. In those cases depending for their 
origin upon the presence in the rectum or sigmoid of impacted 
feces or foreign bodies, their removal is first indicated. Where 



PROCTITIS AND SIGMOIDITIS 203 

the proctitis is caused by ptomaine poisoning from decomposition 
of food material in the intestinal tract, prompt and free catharsis 
is the first essential. Patients suffering from systemic or consti- 
tutional diseases in whom the proctitis is merely a complication 
should of course receive general medical treatment for the under- 
lying constitutional or systemic trouble. 

Where irritating or improper food material is the causative 
factor, or the indulgence in alcoholic stimulants or tobacco in 
excess is responsible, their interdiction and withdrawal are ob- 
vious. 

In the local treatment of acute catarrhal proctitis, copious ir- 
rigations of the rectum, sigmoid, and colon with normal saline 




Fig-. 117. De Vilbiss spray tube, provided with an adjustable tip 
so that the spray may be thrown in any direction. 

solution, at a temperature of 110 to 115° F., given two or three 
times during the twenty- four hours, has in many cases been suffi- 
cient. 

In irrigating the colon, the positions in which the best results 
are achieved are the knee-shoulder, left lateral or Sims', 
or the lithotomy. Where either of the last two positions are em- 
ployed, the hips should be elevated considerably higher than the 
head (Fig. 128). The irrigator, or fountain syringe, to be placed 
from one and a half to two feet above the level of the anus, and the 
flow checked by pressure on the tubing, w^hen there is a desire on 
the part of the patient to expel the fluid before a sufficient quantity 
has been administered. This uncomfortable feeling is due to the 



204 



DISEASES OF THE RECTUM 



overdistention of the bowel at certain points when the inflow 
is interrupted by either the normal sacculations or spasmodic 
contraction of the circular muscular fibers. This sensation will 
soon pass away, however, if the inflow is checked for a moment 
so as to allow the solution already in the bowel to flow higher up. 
Changing the position of the patient from one side to the other 
and massaging the abdomen gently will greatly assist in the dis- 
tribution of the irrigating fluid. By this method, the majority 
of patients will be able to retain a sufliciently large amount of 
the irrigating' fluid to flush thoroughly the entire colon. 

In those cases where the mucous discharge from the rectum or 
sigmoid is profuse, the use of nitrate of silver solution in strengths 




Fig. 11 ; 



Author's rectal spray tube. 



ranging from one to five per cent, by means of the rectal spray 
(Fig. 117), has been found very efficacious. The author uses 
a metal spray tube, attached to the hand atomizer or used with 
compressed air, which is nine inches in length. Its distal ex- 
tremity is closed, but from its circumference, about one sixteenth 
of an inch from the end, the solution issues in all directions from 
four small apertures, so that the solution is not thrown any 
higher into the bowel than one wishes, but bathes all surfaces 
alike (Fig. 118). The rectum and sigmoid are best sprayed 
with the patient in the knee-shoulder position (Fig. 119). In 
some cases, where the mucous flow appears to come from higher 
up in the bowel, irrigations of the colon with various astringent- 
solutions are indicated. Two to five per cent solutions of alum 



PROCTITIS AND SIGMOIDITIS 205 

answer very nicely, and the aqueous fluidextract of krameria, 
from five per cent to twenty per cent as advocated by Tuttle, 
has proved of value in the author's hands. 

While many authors advocate the confining of the patient in 
bed during the treatment of acute catarrhal proctitis, the author 
has found no difficulty in securing results by allowing the patient 
to be up and around for a greater portion of the day. He believes 
that better drainage of the intestinal tract is secured at all times 
by the upright position. In some cases where results are not 
obtained by spraying with aqueous solutions, and where there is 




Fig-. 119. Spraying- the rectum with the patient in the l<;nee-shoulder 
position. On account of the ballooning of the rectal cavity by air in- 
flation in the knee-shoulder position, this position is ideal for the ap- 
plication of sprays to the rectal surfaces. 

a tendency for the bowel wall to ulcerate, the insufflation of 
various powders will be found of great value — iodosyl, com- 
pound stearate of zinc with balsam of Peru or boric acid, and 
thymol iodid have all been found very satisfactory in these cases. 
Ulcerating spots should be treated with pure ichthyol or solu- 
tions of 5 per cent or 10 per cent of nitrate of silver. The author 
is not in sympathy with the use of solutions of the stronger 
chemical antiseptics, such as the bichlorid of mercury or carbolic 
acid, even when used in very weak solutions; he believes that 



206 dise:ases of thk rectum 

more harm is accomplished by the action of the irritating chemi- 
cal solutions on the weak and debilitated lining mucous mem- 
brane than whatever little good they accomplish by their action 
as antiseptics. 

In irrigating or flushing the colon, the recurrent-flow soft- 
rubber colon tube, devised by J. L. Jelks, of Memphis, Tenn., will 
be found a very useful piece of apparatus (Fig. 127). For the 
technic of its use the reader is referred to the following chapter. 
During the treatment of a case of proctitis or sigmoiditis, the pa- 
tient should be kept on a light and unirritating diet in which the 
vegetable elements are largely eliminated. The thin cereal gruels 
prepared from oatmeal, rice, and barley, egg-albumin, the various 
flavored gelatins and liquid peptone solutions, as well as butter- 
milk, will be found best for use in these cases. Milk is contra- 
indicated on account of its tendency to constipate, and the fact 
that it forms hard curds which only further irritate the already 
sensitive bowel. 

Internal medication is not of much avail ; the use of ichthyol 
in 2 to 5 grain doses, given in double capsules four times daily, 
the author believes, has given some good results. He has found 
the employment of white refined petroleum oil, or liquid albolene, 
to be of particular value in proctitis. It seems to have a specially 
soothing effect on the inflamed and irritated mucous membrane 
of the bowel, and while it does not produce or stimulate peri- 
stalsis, it causes easy and free evacuation by its mechanical soften- 
ing and lubricating effect. Being a mineral oil of no food value 
and having no medicinal effect, it is not acted upon by the diges- 
tive secretions, and passes through the intestinal canal unchanged. 

The patient should be instructed to drink six to eight glasses 
of water daily ; if there is any doubt as to the purity of the water, 
it should be boiled and then kept in bottles on ice. In order to 
remove the flat taste of boiled water, the author would suggest 
that before use it be poured into an open vessel or pitcher and 
stirred up with a revolving tgg beater. This aerates the water so 
that it again tastes fresh and clean, and effectually removes the 
unpalatable taste which is one of the drawbacks to the use of 
water sterilized by boiling. The use of flaxseed tea is often of 
assistance in these cases. If properly prepared, it is of distinct 
value. A good way to prepare flaxseed tea is as follows : Take 



PROCTITIS AND SIGMOIDITIS 207 

four or five tablespoonfuls of whole flaxseed and place in a shal- 
low pan. Pour over this a quart of boiling water, place the pan 
over the flame and allow to boil for five minutes, then strain 
through muslin and allow it to cool. It is best kept on ice until 
ready to use. If it is desired to sweeten or flavor the flaxseed 
tea, lemon juice, oil of peppermint or wintergreen, and sugar may 
be added in quantities to taste while the tea is still hot. A tea- 
cupful should be taken as hot as can be comfortably borne every 
night at bedtime. This will act, often, as a mild cathartic and 
seems to have some soothing influence on the mucous membrane 
of the bowel. 

CHRONIC PROCTITIS AND SIGMOIDITIS. 

This disease is usually of two varieties, hypertrophic and atro- 
phic. The atrophic variety is the most common variety of 
chronic proctitis or sigmoiditis. The hypertrophic variety ma}^ 
follow an attack of acute proctitis or sigmoiditis but is often 
produced by other diseased conditions outside the bowel. Pres- 
sure from abdominal tumors, movable kidneys, uterine displace- 
ments, extension from pelvic cellulitis, and adhesions following 
inflammatory conditions of the pelvis may all set up attacks of 
hypertrophic proctitis and sigmoiditis. Appendicitis has also 
been noted as an etiological cause. 

The atrophic variety may often be brought about by a long 
period of chronic constipation, the abuse or excessive use of ca- 
thartics extending over a long period of time, excesses in both 
eating and drinking, particularly in people of sedentary habits. 
Other causes of a more local nature are repeated attacks of fecal 
impaction, the enema habit, foreign bodies in the rectum, and 
unnatural practices. 

Chronic Hypertrophic Proctitis. — This variety is distinguished 
from the atrophic variety by the fact that the mucous membrane 
and submucosa are always thickened, and the glands as well as 
the interglandular connective tissue hypertrophied and increased. 
The anal papillae are usually very much enlarged in this condi- 
tion. On proctoscopic examination the appearance of the mu- 
cous membrane is somewhat characteristic. Tuttle well describes 
it as follows : 



208 dise:asks o^ the: rkctum 

Through the proctoscope it appears edematous, paler than usual, 
and covered with a thin coat of whitish secretion. The swollen mem- 
brane bulges out into the fenestra of the conical speculum or falls 
down and completely covers the end of the proctoscope. When the 
mucopus is wiped off, the membrane presents through the magnifying 
glass a cauliflower-like appearance, whitish and granular. It does not 
bleed easily, and the end of a fine probe being pressed down upon its 
surface, the tissues will meet together above it. By scraping with a 
rectal scoop one may obtain a certain amount of mucopurulent fluid, 
consisting of pus-cells, leucocytes, and various bacteria, together with 
small masses of fecal matter and undigested particles of food. 

Symptoms. — The disease may be of insidious onset, or it may 
be the continuation of an attack of acute catarrhal proctitis. The 
patient is usually in a run-down condition, and presents the usual 
symptoms of such a state, such as impaired appetite, foul breath, 
indigestion, gaseous eructations, diarrhea, occasionally alternat- 
ing with constipation, a frequent desire to defecate without 
much result, and an unsatisfied feeling as if something more 
were to pass away after the stool. Where the passages are loose, 
the stools are inclined to be of a pea-soup consistency, consist- 
ing quite largely of mucopurulent material, or there may be small 
hardened boluses or scybala covered with sticky mucus, or mu- 
copus. On account of the hypertrophied condition of the mucous 
membrane, prolapse is met with in some cases, and pruritus ani 
is a frequent symptom. The secretion keeps the region of the 
sphincter constantly moist and is occasionally so profuse and 
constant that the patient has to wear an absorbent dressing to 
prevent it from soiling the clothes. On account of the constant 
moisture of the part, condylomata are occasionally found, par- 
ticularly at the posterior aspect of the anus and anal canal. 

Diagnosis. — The diagnosis is made upon proctoscopic and 
sigmoidoscopic examination. The characteristic hypertrophied 
appearance of the mucous membrane, with the presence of muco- 
purulent discharge, with or without ulceration of the mucous 
membrane, accompanied by a history of symptoms such as have 
been given above, shotild make the diagnosis not difficult. The 
condition is, fortunately, not very common. 

Tri:aTme:nt. — If upon examination of the patient such ex- 
trarectal causes as appendicitis, floating kidney, or abdominal 
or pelvic growths impinging upon the bowel are discovered, the 



PROCTITIS AND SIGMOIDITIS 209 

indicated surgical measures for their relief should be carried out. 
The patient's dietary should be corrected, and all condiments, 
alcoholic stimulants, pastries, salads, sweets, fresh fruits, and 
freshly baked foods prohibited. 

In order to give as little work to the intestines as possible, 
the patient should be put on a diet which is largely assimilable: 
such as, eggs, buttermilk, gelatins, lean meat, poultry, fresh- 
water fish, and small quantities of green vegetables, such as 
spinach, beet tops, lettuce, endive, and kale. The patient should 
be encouraged to drink large quantities of cold water and should 
try to have a bowel movement at regular hours. Liquid albolene 
in doses varying from one to four drams three or four times a 
day should be administered, on account of its soothing influence 
upon the mucous membrane of the intestinal tract, and because 
by its admixture with the feces it prevents the formation of 
hard, irritating masses. 

Where symptoms of intestinal indigestion are present the 
author has found pancreatin in ten-grain doses, taken with or 
directly following the meal, of considerable value. Ichthyol in 
double capsules, in doses of from two to five grains four times 
daily, seems to be of some service. The bowels should be 
flushed morning and night with some astringent solution, such 
as is used for the treatment of acute catarrhal proctitis. Tuttle 
recommends very highly the use of one to three quarts of a two 
to ten per cent solution of aqueous fluidextract of krameria. 
This is best given with the patient in the knee-shoulder position 
and through a Jelks' recurrent-flow colon tube. The preparation 
of the aqueous fluidextract of krameria is described by Tuttle 
as follows : 

Macerate one pound of bark of krameria in a long percolating tube 
for twenty-four hours. After this a mixture of 20 per cent glycerin 
and 80 per cent water is allowed to percolate through it. The percolate 
should be constantly stirred and refiltered through the bark the second 
time. The filtrate is then evaporated down to one pound, thus ob- 
taining an aqueous fluidextract, containing grain for grain all the 
therapeutic properties of the bark. The preparation should be kept in 
a dark place and not exposed to the air. 

If, on proctoscopic or sigmoidoscopic examination, localized 
ulcerated areas (Fig. 120) are discovered, they should be sprayed 
with a 1 to 3 per cent solution of nitrate of silver or 5 per cent 



210 



DISEASES OE THE RECTUM 



solution of ichthyol. They may be stimulated by the application 
of nitrate of silver, 10 per cent, or pure ichthyol or balsam of 
Peru, applied with a long-handled applicator. The general con- 
dition of the patient must be improved by ordinary tonic meas- 





Fig". 120. Ulcer of the rectum. This case weU illustrates the im- 
portance in proctoscopy of examining- the cavity behind each rectal 
valve. In this patient the ulceration was situated on the right lateral 
■wall of the rectum, and had not the first rectal valve been pushed 
aside by the proctoscope, its presence might have escaped unnoticed. 

ures and the encouragement of moderate exercise in the open 
air and sunshine. 

Chronic Atrophic Proctitis and Sigmoiditis. — This variety is 
more common than the hypertrophic, and consists of a general 



PROCTITIS AND SlCxMOIDlTlS 211 

atrophy of both the glands and intraglandular structures of the 
rectum and sigmoid. It differs from the hypertrophic variety in 
that it does not frequently extend higher than the sigmoid flex- 
ure, and there is a thinning or destruction of the mucous mem- 
brane lining of the bowel. The pathology of the condition is 
well described by Tuttle as follows : 

One observes upon examining the mucous membrane in these cases 
an irregular, bosselated, or granular appearance. The surface is dry, 
rough, inelastic, and without any salient vegetations. Attached to the 
surface here and there are small masses of dry fecal material, and 
occasionally little islands of necrotic epithelium or pseudomembrane. 

Microscopic examination shows the epithelium absent in many places, 
but always present in the deeper portions of the crypts of Lieberkiihn. 
These follicles are generally atrophied, the intratubular tissue de- 
creased, and their goblet-cells are few in number. The cylindrical 
epithelium is said to assume the stratified pavement type in this dis- 
ease. This change does not extend more than one or two centimeters 
above the anorectal line; it is confined to the superficial structure of 
the membrane, and does not involve the tubules. 

The connective tissue of the submucous coat is dense and slightly 
thickened; it does not contain embryonic tissue and elastic fibers, as 
in the hypertrophic form. The solitary follicles are often enlarged 
and distended. At points there are distinct granulations, and ulcera- 
tions, accompanied with hyperemia and multiplication of the blood- 
vessels, but there is no alteration in the blood-vessel walls. 

Symptoms. — As has been stated, this condition supervenes 
freqtiently on an old long-standing case of constipation. The stools 
are small, hard, and dry, and their passage is painful ; they are 
often streaked with blood, pus, and mucus. The patient stiffers 
from tenesmus, referred pain in the sacral region and down the 
legs. The rectuni. feels hot, and after stool it feels as if it were 
not emptied. This feeling is not like the sense of fulness which 
is more characteristic of the hypertrophic variety ; but more a 
sense of uneasiness which focuses the patient's attention upon 
the rectum, which makes him feel that the emptying of the rec- 
tum will bring him relief. Prtirittis ani is a frequent symptom as 
well, as is spasm of the sphincters. On account of the contracted 
condition of the anal canal, the passages are frequently followed 
by the production of small fissures or cracks in the mucous 
membrane. Their presence adds a stinging or burning sensa- 
tion to the other symptoms of the disease. These fissures are 



212 DISEJASKS O^ THE RECTUM 

very superficial and are not to be confounded in any sense with 
the true or typical anal fissure. They consist merely of linear 
abrasions in the lining membrane of the anal canal, and lack 
any tendency to chronicity which is characteristic of a true 
fissure. Hemorrhoids are said to be found frequently accom- 
panying this condition. 

With the patient in the knee-shoulder position, proctoscopic 
examination shows the mucous membrane to be reddened, but 
not markedly as in the acute variety, dry, covered here and there 
with small flecks of dry fecal matter. The insertion of the proc- 
toscope is usually accompanied by some hemorrhage due to the 
passage of the instrument. On examination of the rectal walls 
numerous pin-point ulcerations are met with. The mucous se- 
cretion, which is very slight in this condition, clings to the 
bowel wall, and is characterized by thickness and tenacity. In 
this variety the mucous membrane does not fall together before 
the proctoscope, and the rectum gives the appearance of being 
a stiff tube, while the rectal valves stand out very markedly. 
Ulcers other than the pin-point variety are not uncommon, and 
tend, when present, to become chronic and gradually to encircle 
the bowel, producing a strictured condition. 

Treatment. — In this condition the presence or absence of 
syphilis should be ascertained. Where either from the ignorance 
of the patient of his true condition or from his reticence about 
the matter one cannot obtain a definite history, the Wassermann 
test, or serum diagnosis, should be resorted to. If positive, the 
ordinary measures for the treatment of syphilis in the third stage 
should be employed, the intravenous administration of salvarsan 
being of the greatest value in those cases. 

The diet is exactly the same as that outlined for hypertrophic 
proctitis, with the exception that the patient may have fatty 
food, bread (not freshly baked), toast, rice, sago, and custards. 
Where intestinal indigestion is present, pancreatin should be ad- 
ministered and liquid albolene given, as outlined in the treat- 
ment of the hypertrophic variety. As this condition is usually 
confined to the rectum and lower sigmoid, the high irrigations 
will not be necessary, but the solutions mentioned are equally 
applicable for the flushing of the sigmoid and rectum in this 
variety. After irrigating the rectum, the patient should be put 



PROCTITIS AND SIGMOIDITIS 213 

in the knee-shoulder position, and under the guidance of the 
eye, ulcerated patches on the mucous membrane should be 
touched up through the proctoscope with two to five per cent 
solution of nitrate of silver, iodin, or pure icthyol. Icthyol 
in five per cent aqueous solution is very valuable as a spray in 
this condition, as is the fluidextract of krameria in strengths rang- 
ing from twenty to thirty per cent. The treatment of the ac- 
companying conditions, such as fissures, hemorrhoids, and pruri- 
tus, should be carried out as outlined under the respective chapters. 
What has been said before regarding exercise and fresh air is 
equally applicable in this condition. 



CHAPTER XIII. 

DYSENTERY. 

By John L. Jei^ks, M. D., Memphis, Tenn. 

GENERAL CONSIDERATIONS. 

Synonyms. — Colitis, die rote Ruhr, or Dysenterie (German), 
Difficultas intestinorum (Latin), A{5? evrepov (Greek). 

Definition. — An acute or chronic inflammatory disease, usually 
affecting the large intestine, beginning in the rectum, but some-, 
times extending into the small bowel. In the acute form it is 
characterized by pain, tenesmus, and frequent passages of bloody 
mucus. In the chronic form the patient suffers recurrent at- 
tacks of diarrhea alternating with constipation. 

Historical. — Dysentery was one of the best-known diseases 
of antiquity. Even before the time of Hippocrates, reference 
to it was made, the earliest being that found in the papyrus 
of Ebers.' Hippocrates, in the year 460 B. C, was the first 
writer to give a fairly accurate description of its symptomatology, 
pathology, and sequelae. 

Other well-known writers were Celsus, the medical Cicero of 
his day (45 A. D.), Aretseus, Galen, and x\lexander of Tralles. 
Then for more than a century little further knowledge was im- 
parted until the time of Antonio Benivieni (1506), and Thomas 
(1833), who refuted many of the erroneous ideas of his prede- 
cessors. Woodward (1879) gave a most excellent history of 
this disease. 1 Kartulis, in Egypt (1885), Elexner (1890), 
Councilman and Lafleur (1892), vShiga, of Japan (1879), Strong 
and Musgrave, McDill, of Manilla, and Harris of Atlanta, of the 
present era, have contributed perhaps the most valued writings. 
Osier, Tuttle, and Surgeon General Sternberg, of the United 
States Army, are also among those who have furnished data in 
our own country. 

The author of this chapter has also made close study of this 
disease in the Southern states. 



IMedical and Surgical History of the War of the RebeUion, Vol. 2. 

214 



dyse:nte:ry 215 

Geographical Distribution. — Dysentery does not respect any 
country, climate, or race. Ayers very truthfully states that 
where man is found there some of its forms appear. A. Hirsch 
says that it had a wide distribution over the inhabited earth at 
all historic times. It is without doubt one of the four great 
epidemic diseases of the world. In the tropics its ravages have 
been most deadly, destroying more lives than cholera, and to the 
armies it has been more destructive than powder and shot 
(Osier), and it has been shown that the ameba is the prevaiHng 
etiologic factor in the disease as observed in the Southern 
states. Dysentery is a destructive giant compared to which 
strong drink is a mere phantom (McGregor). The worst out- 
breaks occur as endemics in the tropics and decrease as we leave 
this latitude, while in the higher latitudes it seldom appears in 
this type, though now and then in greater or less epidemics. A 
very striking fact relative to this affection is that it involves the 
cold zones. Epidemics have been reported in Alaska, Sweden, 
Russia, Greenland, and Iceland, also other of the colder coun- 
tries. 

General Etiology. — Skasox. — Among the predisposing causes 
season is the most important. More cases of dysentery are found 
during the summer and autumn months. This is due to several 
reasons. Sudden changes in temperature, especially sudden rises, 
have a most marked effect. It is most prevalent in the warm 
climates, and as stated above, it is most deadly in the tropics. 
Therefore, climate should be mentioned as one of the causative 
factors. 

Race;. — Race itself does not seem to aft'ect this disease. Strange 
though it may seem, the negro race in the South has not seemed 
to suffer much, with reference to this disease; notwithstanding 
the baneful consequences of poor hygienic conditions, as over- 
crowding, improper food, poor ventilation, filth, thin clothing, 
and especially syphilis — a disease almost universal among this 
race, either inherited or acquired. These, however, must all be 
included under predisposing causes. 

Sex. — Under etiology, we should also mention sex. Within 
our experience, which is not at variance with that of other 
writers, dvsentery is much more common among males. 

Poor Hygii:xe:. — In the slums of our cities, where filth abounds 



216 DISEASES 01^ THE RECTUM 

and where proper sewerage is lacking, we find more cases of 
dysentery than in the sections where the hygienic conditions are 
better. Many cases are found in institutions, such as insane 
asylums, barracks, jails, and army camps. Wherever there is 
overcrowding, there is very likely to be found a large percentage 
of dysenteric cases. During the Civil War, Woodward reported 
259,071 cases of acute dysentery, and 28,451 of the chronic 
form, in the Federal service alone. 

Topography and Condition of Soil. — Investigators have 
tried to associate dysentery with certain topographical condi- 
tions, or with conditions in the soil, but have been unable to do 
so. 

Epidemics have proved more fatal in the country than in the 
city. 

Soil that is badly contaminated with dysenteric excreta is a 
great source of infection. Czernicki tells about dysentery break- 
ing out in two French squadrons in 1875 that were on the same 
ground occupied a short time previously by a cavalry regiment 
which had been affected with the same disease. 

The writer has often found nests of dysenteric cases in the 
low flat mill districts of the city, and in marshy lowland sections 
of the country. No doubt, owing to the character of the soil in 
these localities, seepage contamination of drinking-water sources 
sometimes occurs. Houses built upon a low damp soil are un- 
sanitary, and when the surrounding soil always remains saturated 
with moisture, there exists a favorable condition for the de- 
velopment of dysentery. The peculiar emanations from soil of 
this kind have always been considered very harmful. It is 
thought that they have a depressing influence upon the inhabit- 
ants, and thus make easier the inroads of diseases. 

In one ill-drained district of Memphis, the author has treated 
nine cases of amebic dysentery within a radius of two blocks, 
and another case was treated that had been infected in the 
same territory five years before. It is also an interesting fact to 
note here that two families, in which were four of the patients, 
purchased vegetables from the same Italian huckster. 

There is yet another reason why we find more cases in marshy 
lowland districts. Here we find the greatest growth of vegeta- 
tion, which, when conditions are favorable, furnishes a most suit- 



DYSENTERY 217 

able nidus for the propagation and development of amebse, bac- 
teria, and other micro-organisms. 

Foods. — Certain articles of food are unquestionably predis- 
posing causes of dysentery. This fact is not due so much to an 
idiosyncrasy to some particular foods, but mainly to the micro- 
organisms which they contain, and to the putrefactive changes 
which occur within the intestinal tract. All groundling vegetables 
and fruits, especially those shipped from the tropics, are possible 
sources of infection. 

Undoubtedly infections with the amebae have been traceable 
to eating such vegetables as lettuce, strawberries, cress, and 
potatoes. 

Eating food in excess, and the resulting attacks of indigestion, 
often pave the way for dysentery. 

Drinking Water. — The author has given much thought to 
water supply as a medium through which dysenteric infections 
are conveyed. This is undoubtedly the most common source. 
We have been impressed by the fact that many cases are found 
among sportsmen, also timbermen who spend much of their 
time in the woods, and who drink, when necessity requires, from 
surface pools, springs, and slashes. 

The author has treated cases of amebic dysentery from a 
country district with which he is quite familiar, and has knowl- 
edge of the fact that the disease was contracted in the same in- 
fected neighborhood in which twenty years previously another 
case had lived, which proved fatal. The fact has been elicited 
that many of the author's cases had neighbors who were suffer- 
ing in like manner, and who were procuring their drinking water 
from the same source. 

There are certain rivers in China whose waters are known to 
cause dysentery. 

In 1863, the number of cases among the workmen construct- 
ing the Suez Canal was decreased when the better water of the 
Nile was used. 

The author has treated one case of amebic dysentery in the 
person of a physician, who thinks undoubtedly that the infection 
was obtained from drinking Mississippi River water while on 
board a river steamer. Thevenol says, ''Nothing is so prone to 
lead to disorganization of the large intestine as infected water." 



218 dise:asks o^ thk rkctum 

Impure water itself does not produce dysentery, but only when 
it contains the special micro-organisms. 

ACUTE CATARRHAL DYSENTERY OR SPORADIC 
BACILLARY DYSENTERY. 

This form is the least severe and most common form that is 
encountered. It occurs both sporadically and endemically. This 
type is characterized by the frequent passage of great quantities of 
mucus. 

Etiology. — Children principally are infected with this form, 
but we often see it in adults, most often complicating other 
diseases. It is the kind of dysentery that accompanies all of 
the exanthemata. We see it, in fact, complicating almost all of 
the acute infectious diseases. Still another important cause is 
the ingestion of certain kinds of foods, or other irritating sub- 
stances. The ordinary attacks of enterocolitis in babies during 
the summer months come in this classification. Most of these 
attacks are due to milk poisoning. 

Pathology. — Macroscopically a superficial, acute inflamma- 
tion involving the large intestine, but sometimes extending into 
the small bowel, is seen. The tendency of such cases is to re- 
cover without necrosis. Sometimes, though, in the more severe 
attacks, the mucosa will become injected to such a degree that 
small ulcerations occur. In these cases the mucus is often stained 
or streaked with blood. 

Microscopically, are seen the Bacillus coli communis, also the 
Trichomonas intestinalis, and Paramoecium coli, and occasionally 
the Cercomonas intestinalis. We also find red blood-corpuscles 
and leucocytes, and always large numbers of desquamated epi- 
thelioid cells, dotted about with fat globules and vacuoles. 

Symptoms. — The onset is sudden and usually ushered in 
by an attack of cholera morbus, or by an attack of acute indi- 
gestion. Sometimes a more or less distinct chill may occur at 
the onset. 

Nausea and vomiting are not rare symptoms. 

The tongue has a moist coat at first but soon becomes dry. 

From the first there is diarrhea. Pain is complained of over 
the entire abdomen, also tenesmus, and severe griping pains. 
The patient is extremely restless and cannot get relief from 



DYSENTERY 219 

a desire to stool. The bowel movements are at first free, and 
watery, or sero-sanguineous, but later on, contain only small 
quantities of mucus streaked or stained with blood, and have an 
offensive odor. 

A slight elevation of temperature usually accompanies this 
form, but in more severe cases, it may reach 103° F. There is 
corresponding acceleration of the pulse, and the patient complains 
every few minutes of thirst. 

The stools, during the first day or two of the attack, contain, 
in addition to the above-mentioned materials, small fecal masses 
(scybala). Sometimes, during the course of the attack, the 
stools contain an excess of bile and cause intense burning while 
passing. 

The ordinary cases of acute catarrhal dysentery are self- 
limited, usually recovering in a week. Some are so mild that 
treatment is not sought. It must be remembered, however, that 
the cases which begin with mild symptoms may develop graver 
ones at any moment. 

Diagnosis. — The diagnosis is very easy. The cramping 
pains, tenesmus, and frequent passages of mucus and blood are 
positively diagnostic. If, however, a case may be obscure, the 
microscope and proctoscope will at once clear it up. 

Prognosis. — In most cases the prognosis is favorable, but 
it is best to be guarded at all times in giving it, since some of the 
cases, which at first seem quite mild, may terminate adversely. 
Ordinarily, though, the symptoms will subside in a week, and 
the patient will recover rapidly. There are always rapid emacia- 
tion and weakness. 

DIPHTHERITIC DYSENTERY. 

Definition. — This is an inflammation, usually confined to 
the lower part of the colon, and rectum, but sometimes extend- 
ing into the small bowel. It is accompanied by a croupous, or 
true diphtheritic, exudation. It is one of the epidemic forms 
found in Japan, also in armies, in insane asylums, and ships, or 
wherever large numbers of people are crowded together. 

Etiology. — This form of dysentery is caused by the 
Bacillus dysentericu, discovered by Shiga in Japan (1897). Flex- 
ner and Strong encountered the same bacillus in one of the forms 



220 DISEASES 0^ THE RECTUM 

of the disease which prevails in the PhiUipines and Porto Rico. 
The bacillus is described by Shiga as being a short rod with 
rounded ends, and closely resembling the bacillus of typhoid 
fever. It possesses slight motility. Flexner discovered that the 
bacillus ''is inactive to blood-serum from typhoid fever cases, 
but reacts with serum from dysenteric cases to which Bacillus 
typhosus does not respond." Shiga's bacillus may be found 
within the body as late as one year after the primary infection. 

Pathology. — The mucosa, if the attack is not severe, is 
coated with a yellow exudate. Slight ulceration of the mucous 
membrane over the tops of the folds of the colon is seen. 

In severe attacks, however, all the layers of the colon are in- 
volved, and it appears greatly enlarged. The infiltration is so 
great that extensive necrosis takes place. The mucous membrane 
over the entire colon presents a pufify or swollen condition, yellow 
in color. Large areas may slough en masse. 

Microscopically, this slough is found to consist of a fibrinous 
and cellular exudative coating over the mucosa. 

The glands of Lieberkiihn are destroyed, and sometimes no 
trace of them is found. 

Symptoms. — The symptoms are practically the same as 
those of acute dysentery greatly intensified. The onset is more 
severe. The chill is often present, and the fever is high, running 
an irregular remittent course. The pulse is greatly accelerated ; 
tormina and tenesmus are most severe. 

Delirium is common. Bowel movements may at first be loose 
and watery. Soon great quantities of sero-sanguineous dis- 
charges, containing bloody mucopurulent material, and sloughs 
of variable sizes, are passed. The distention of the abdomen is 
greater, and pain is more severe. There is more rapid loss of 
strength. 

Diagnosis. — The diagnostic points of most value are the 
character of the dejections, which may contain pseudomembranes, 
severe symptoms, and the appearance of epidemics. 

The positive diagnosis is by the agglutination test. 

Complications. — Complications in this form are encountered 
more frequently. 

Perforations sometimes occur and are almost invariably fol- 
lowed by peritonitis. 



DYSENTERY 221 

Liver abscess is another grave complication. 

Nephritis, phlebitis, pericarditis, endocarditis^ and pleurisy 
have also been noted. 

Grave symptoms referable to the central nervous system, due 
to toxin poisoning", denote a complication of serious moment. 

Recovery sometimes takes place, but usually after a more or 
less chronic course. 

SECONDARY DIPHTHERITIC DYSENTERY. 

The lesions of this form are similar to those of the last de- 
scribed, but not so severe. The secondary, as the name implies, 
usually follows one of the acute, or chronic, diseases, as pneu- 
monia, nephritis, pericarditis, endocarditis, pulmonary phthisis, 
typhoid fever, and numbers of other varieties. 

Symptoms. — The symptoms are sometimes not very notice- 
able. The griping pains and tenesmus are not very severe as a 
rule. The patient has about two to six loose bowel movements a 
day. Anatomically, the inflammation is very superficial, only the 
upper layers of the mucosa being involved. The inflammation 
may progress, producing more or less necrosis. A'ery little blood 
is found in the stools. 

Prognosis. — The patient will often perish. Owing to 
adynamia already existing, much resistance is impossible. 

AMEBIC DYSENTERY. 

Synonyms. — Amebic colitis, amebic enteritis, amebiasis. 

Dysentery in this form is both epidemic and endemic in the 
tropical countries, especially India, Africa, and the Phillipine 
Islands. In the United States sporadic cases are met fre- 
quently. Osier says that his cases in the Johns Hopkins Hospital 
were almost exclusively amebic. It is very rare, indeed, that the 
author is called upon to treat a case of the severe acute or 
chronic type in which he is unable to make a positive diagnosis 
of amebic infection by means of the microscope. 

This is the prevalent type of the grave, chronic, and relapsing 
cases of dysentery in this country, and many of the supposed 
diphtheritic dysenteries are of this origin. The microscope only, 
however, can verify or refute this opinion. 



222 



DISEASES OF THE RECTUM 



Alany cases of amebiasis have been diagnosed by the author 
when no history of dysentery or even diarrhea was obtained. 
He has also operated on two cases of amebic hver abscess, when 
the most careful inquiry failed to reveal a past or present history 
of the symptom dysentery or diarrhea. 

Etiology. — This form of dysentery is caused by the 
Bntaryioeha histolytica or the Amooha dysentericu (Fig. 121). 
(Councilman and Lafleur.) 




Fig-. 121. Amoeba histolytica (Schaud). A, young specimen; B. 
an older specimen crammed with ingested blood-corpuscles; C, D, E. 
three figures of a living ameba, which contains a nucleus and three 
blood-corpuscles, to show the change of form and the ectoplasmic 
pseudopodia; n. nucleus; b.c, blood-corpuscles. — After Jvirgens, from 
Albutt's System of Medicine. 



It is a type of protozoon. unicellular, and motile, several times 
the size of a red blood-corpuscle. In structure the organisms 
have an outer colorless zone, called the ectosarc or hyaloplasm, 
and an inner granular zone, the endosarc or endoplasm. Its 
nucleus is eccentrically situated, and one or more vacuoles are 
present. This parasite is phagocytic in character, and may be seen 
to contain red blood-cells, bacilli, vacuoles, and other particles. 
It is easily mistaken for a large epithelial cell, or Paramecium, 



DYSENTKRY 



223 



when not in motion. It is ten to fifty microns in size. The 
Amoeba histolytica multipHes by segmentation, the nucleus and 
endoplasm dividing in such manner as to form several embyro- 
cells for the corresponding number of new cells. The old cell 
either dies or enters into the encvsted state. After an uncertain 




-« 



Fig-. 122. Amoeba coli mitis. A and B, Uving- amebae, showing- 
changes of form, and vaciiolation in the protoplasm; C, D, E, amebse, 
showing different conditions of the nucleus (a); F, a specimen with 
two nuclei, preparing for fission; G, a specimen with eight nuclei, pre- 
paring for multiple fission; H, an encysted ameba containing- eight 
nuclei; I, a cyst from which young amebae (al) are escaping; J, K, 
young amebge. free. — After Casagrandi and Barbagalli, from Albutt's 
System of Medicine. 

period the cell-wall bursts, and liberates the new cells. The 
mother-cell, containing the daughter-cell, may remain encysted 
for an indefinite time. In this state it is much smaller than 
the ameboid form, and is non-pathogenic. 



224 DISEASES O^ THE RECTUM 

There are two well-recognized species of amebse, the kind 
above described, and the Amoeba coli mitis (Fig. 122), which is 
occasionally found in healthy persons. This organism is also 
found in other bowel affections. It is non-phagocytic, twelve to 
thirty-six microns in size. Propagation is by gemmation or 
budding; a portion of the cell body being thrown out and then 
broken off, forming a new individual.^ 

All authorities now agree that the bacteria of symbiosis, and 
other associated micro-organisms, have much to do with the 
pathogenicity of the amebae.'" 

I have observed with much interest certain of these symbiotic 
bodies, as also rod-shaped bacilli contained in the ameba in a 
class of cases to be referred to later. 

The ameba is not the only pathogenic organism to be consid- 
ered, therefore, during an attack of amebic colitis, for the colon 
bacillus is known to produce many of the pathological condi- 
tions in these cases ; so, this and other bacillary infections may at 
any time supersede in importance and virulency amebic infection ; 
therefore this fact and possible complication must at all times 
be kept in mind, and in this emergency met with proper treat- 
ment and diet. 

1 have noted that the cases presenting themselves during the 
summer or autumn usually show the more active and phagocytic 
amebse, or, more properly speaking, in those cases in which I 
have found the more active and phagocytic amebae, I have also 
found the greater virulence. In making microscopic examina- 
tions of most cases, the parasites are either very inactive or 
cease motility quickly, rendering necessary at times two or three 
examinations to make a positive diagnosis. In most cases the 
bacteria of symbiosis are quite numerous. 

The amebic are introduced into the intestinal tract through the 
mouth and stomach, but the acid gastric juices prevent their 

2 After close observation, covering- a g-reat number of cases, the 
author has become convinced that there exists a pathog-enic ameba 
which does not correspond exactly with the description above g-iven 
of the Amoeba histolytica. 

This ameba is smaller, the hyaloplasm is not so distinct, though its 
lighter zone is discernible, and this hyaloplasm or ectosarc can be 
seen forming- pseudopodia. This ameba is both granular and phag-ocytic, 
and is often observed very active, hence, in the author's opinion, this 
ameba is likewise pathogenic. 

3 The Balantidium (Paramoecium) coli must be reckoned with as being 
responsible in part or wholly for some cases of colitis, and this parasite 
is alvirays considered responsible for a part of the pathological con- 
ditions, when observed associated with the amebse. 



DYSE^NTERY 225 

propagation. They pass on into the colon to gain lodgment at 
favorite points, namely, the ileocecal valve, hepatic and splenic 
flexures, and especially upon the plicae transversalis recti. In 
most cases the inflammation begins first in the rectum and ex- 
tends upward by continuity. 

The author has endeavored to explain the periods of exacer- 
bation and amelioration of symptoms, in the following ways: 

First. — The Entamoeba histolytica is especially fond of feed- 
ing on juicy subepithelial structures, and in a given case, this 
particular crop or generation, within the plentiful surroundings, 
may become indolent and easily satisfied, and also less active 
in the process of sporulation. 

Second. — The parasite may be in a state of encystation, dur- 
ing which period the amebae remain dormant or non-pathogenic 
until finally a difi'erent generation produces a more active and 
phagocytic type. 

Third. — Because of the presence of a greater or less number 
of bacteria of symbiosis, which, in the light of observation of 
most authorities, seem essential to the activity and virulency of 
the amebae. 

A further study of the problems of immunity may in the 
future yield information which will be of paramount importance 
in amebic dysentery, in reference to both the ameba and the 
symbiotic bacteria. 

This disease is most often contracted through drinking water, 
raw vegetables, and fruits. 

Flies and other insects are possible means of transmission. 

It can also be developed through contact, as from the use 
of syringe tips which had been used in treating an amebic case 
and not sterilized. 

When making a microscopical examination of the feces for 
amebae, the following technic will be helpful to the inexper- 
ienced microscopist : 

Warm the slide slightly. Secure a small bit of the mucus 
from the stool and place upon the slide. Cover with a cover- 
glass quickly, and press it gently until the material is thinly 
distributed. Examine at once with the one-sixth or the oil- 
immersion objective. This should be done as rapidly as pos- 
sible, since the amebae retain motility for only a short time 



226 disease:s 0^ thk ri^ctum 

in temperatures much lower than body heat. If now they can- 
not be found, apply warmth by holding an electric-light bulb 
to one side of the stage. They may then be seen. Never be 
positive that the amebse are not present though not found. They 
may be in a state of encystation in the tissues, and only after 
an acute exacerbation of the disease, will they be found. 

A still better plan, and the only accurate way, is to examine 
the scrapings of the ulcerated mucous membrane. This method 
should always be practiced, when possible, after a saline cathar- 
sis. 

The most important of the associated organisms are the Strep- 
tococcus, Staphylococcus, Bacillus coli communis, Trichomonas 
intestinalis, Paramoecium, Cercomonas intestinalis, Lamhia intes- 
tinalis, Bacillus pyocyaneus, and others. 

Pathology. — Pathological lesions are almost always con- 
fined to the rectum and colon, but occasionally the ileum may 
become involved. 

Appendicitis is quite common. 

The mucosa appears red and congested, and covered with mu- 
cus, usually tinged with blood. 

The infiltration and edema now invade the submucosa, ne- 
crosis of the overlying mucous membrane takes place, and the 
amebic ulcer is formed. This necrosed area may be oval or ir- 
regular in shape and appears to project over the level of the 
mucosa. 

The amebse gain access into the submucosa through the in- 
terglandular spaces and carry with them the associated or- 
ganisms. Here they set up an active inflammation, and produce 
ecchymosis and swelling of the glands. The number of the 
amebse in the submucosa is great, since they prefer this juicy 
subepithelial tissue, no doubt because they find food more easily. 
When they get into the submucosa, their presence excites a 
reactive inflammation at once. 

It is important to note here that the bacteria of symbiosis 
play a very important part in the inflammation just described. 
Necrosis now takes place in the inflammatory area, and slough- 
ing follows. In grave and fatal cases this undermining pro- 
cess, so to speak, may become so extensive, and the congestion 
so great, that large areas will necrose and slough. The author 



dyse;nte:ry 



227 



has preserved one specimen of this character twenty-eight inches 
in length (Fig. 123). 

The muscular coat of the bowel offers greater resistance 




Fig, 123. Slough of mucous membrane, 28 inches in length, from 
a fatal case of dysentery. Photograph of specimen from one of Jelks' 
cases. 



to the amebae, so that they seldom invade it. Occasionally, how- 
ever, this undermining process will extend into the intermus- 
cular tissue, and produce the same results as before described. 



228 



DISEASES 0^ THE RECTUM 



In this way the larger and deeper ulcers form (Fig. 124). 

The involvement of the rectum in one case was so extensive 
that the new scar-tissue produced an almost complete stenosis. 
Higher up the ulcerations usually cover a smaller area. A 
sharp-edged, clean-cut ulcer results, or a simple erosion only 
may be observed. This ulcer may involve the greater portion 
of the thickness of the wall of the bowel, but the undermining 
is not so extensive and the thickening that results lower 








-i%J,(;t3/ 



Fig-. 124. Edge of intestinal ulcer. (Toluidin-blue and eosin. 
1 inch. Oc. 3.) — Courtesy of Dr. H. F. Harris, Atlanta, Ga. 

a. Mucous coat which projects over ulcer at f. 

b. Submucosa. 

c. Circular layer or muscle-fibers. 

d. Tissues of mesocolon. 

e. Amebse in dilated lymph-spaces. 



Beck 



down is not so marked here. One post mortem revealed nine 
distinct perforations 'in the splenic flexure, which produced sud- 
den death when the loose attachment of the omentum was broken 
by gaseous overdistention. 

The author wishes also to call attention to certain spots and 
lines which he considers almost diagnostic when present. By 
careful examinations with the proctoscope small red papular 
spots may be seen dotted about among the already well-defined 



DYSENTERY 



229 



ulcers. Perhaps on the foUowing day the red spots will show 
a little white or yellow point of necrosis in its center. Upon 
the next examination an ulcer will be seen to have taken its place. 
In another instance a few circinate or ringworm-like lines 
in the mucosa, a picture which is not observed in other forms 
of intestinal infection, will be seen. These lines or ulcers are 
chieflv submucous, but sooner or later break into the under- 




Fig. 125. 
Tuttle. 



Dysenteric ulceration on the valves of Houston. — After 



mined ulcer, and may then assume any shape. Xew lines will 
form, however, to tell the story (Fig. 125). 

The author has also observed small openings at points along 
the courses of these circinate lines leading to extensive sub- 
mucous ulcers. At other times the intestinal mucosa presents 
only a few circinate lines overlying the subepithelial ulcers, 
while the remaining mucosa presents a red granular appearance. 

In a few cases (unmistakably amebic) the disease appeared 



230 • DISEASES OE THE RECTUM 

to be only a hypertrophic proctitis, or a proctosigmoiditis, and 
in others the mucosa appeared puffy or edematous. 

It is very probable in my opinion that some of these condi- 
tions were concomitant and due to associated conditions, es- 
pecially collateral infections. This important fact must not be 
lost sight of : the pathological conditions produced by the ameba, 
as also the amebse themselves, are mostly submucous ; while the 
collateral infections and the conditions produced by them are', 
as a rule, superficial. 

Amebse have been found free in the peritoneal cavity, and in 
other parts of the body, especially the liver. Here, when unas- 
sociated with collateral organisms, the parasites are non-pyogenic. 
A true amebic, unassociated infection in the liver would mean 
simply that ; and not an abscess cavity filled with the most of- 
fensive pus, as is so often found. Perhaps, in almost all cases, 
amebse have been conveyed into the liver, and but for the fact 
that they were unassociated with pyogenic organisms, abscesses 
would surely follovv^. Hepatic abscess complicates probably 
twenty per cent of all chronic amebic infections ; however, exact 
statistics cannot be obtained. 

Councilman found this complication in six out of eight au- 
topsies. 

Strong and Alusgrave found it in fourteen out of ninety-seven 
autopsies. 

Out of a series of twenty-five cases treated by the author in 
1908, four were complicated by hepatic infections. In two of 
these cases the diagnoses were verified by operations. In one 
a large abscess of the right lobe was found, and in the other 
the right lobe was inflamed and firmly adherent to the omentum 
and hepatic flexure of the colon. A cholecystitis was also pres- 
ent, and required drainage for six weeks. 

The infections may be carried into the liver in two ways: 

First, and most probable, through the portal vein, which has 
often been found infected (Plate IV). 

Second, by transmission through the intestinal wall. 

Craig claims that the kidneys often present the lesions of 
acute parenchymatous nephritis. 

Symptoms. — In the more virulent or malignant cases the 
onset is usually sudden, and may or may not be ushered in with 






^ * 



'^^ 






^..^,..^A 



«. % 



PLATE IV 

Section of intestine just below ulceration. (Toluidin-blue and eosin. 
Beck, 1/4, Oc. 3.) In upper portion of the field a large vein is seen; 
the wall of the vessel which is nearest the ulceration is being- in- 
filtrated with small cells, and amebse are breaking down; both red and 
white cells and amebee are seen within the lumen of the vessel. In 
the lower portion of the field many amebae are seen — some in the 
tissues, and others in the lymph-spaces and Ij^mph-channel. — Courtesy 
of H. F. Harris. Atlanta. Ga. 



DYSENTERY 231 

a rigor. The attack is preceded by a period of malaise, often 
accompanied by constipation. An attack of acute indigestion 
often precedes this form of dysentery. The patient may have 
six to forty bowel movements during the first twenty- four 
hours, usually sero-sanguineous in character. Prostration is 
early. By the second or third day considerable blood and pus 
begin to appear, the latter being very offensive in odor. Pros- 
tration increases with the further absorption of toxins. Tem- 
perature usually rises to 102 to 103 degrees F., and is of the ir- 
regular remittent type. Delirium may be pronounced. Gen- 
eral abdominal pain and tenesmus with tympanites and tormina 
are prominent. The facies abdominalis denotes suffering and 
anxiety. The nose is pinched, and the upper lip is retracted ; 
and the condition now is a grave one. The thighs are flexed 
upon the abdomen and legs upon the thighs in such manner as 
to relieve pressure upon the abdominal viscera. Considerable 
tenesmus precedes and accompanies all bowel movements and 
may follow for several minutes, though as a rule a greater or 
less relief follows the passage of only a small amount of bloody 
mucus. Later the more offensive discharges, containing greater 
quantities of mucus, pus, and blood, with perhaps mucofibrinous 
casts, or mucous membrane sloughs, indicate necrosis. 

The above symptoms are soon followed by delirium, subnor- 
mal temperature, rapid, feeble pulse, clammy perspiration, glazed 
skin, collapse, and death. If, after the sloughs are passed, the 
patient survives the sepsis and toxemia, and healing of the ul- 
cers follows, the process is a slow one. These ulcers are finally 
filled with granulation tissue and fibrinous material, which 
contract, causing more or less stenosis. The symptoms of sepsis 
and toxemia from the absorption of necrotic material and toxins 
very gradually diminish until the patient is able to resume his 
regular occupation. 

The following case reports will be helpful : 

Case 1. — Name, Dr. ; age, 36 years; race, white; occupation, 

physician; family history, negative; previous state of health, good, 
until six months previous, during which time he suffered a rapid decline. 
Symptoms: Lost thirty or forty pounds in weight; complained of 
slight colicky pains over course of colon; troubled with loose fermenta- 
tive diarrhea; inactive liver; coated tongue; temperature 99 2/5° F.; 



232 DISEASES 01^ THE RECTUM 

pulse, 60; skin, dry and muddy; slight tenderness on pressure over 
cecum, hepatic and sigmoid flexures; pronounced melancholia, in- 
somnia, and malaise were present. Had not noticed passages of mucus 
from bowel but spoke of a very offensive odor. Proctoscopy revealed a 
considerable quantity of sanguino-purulent mucus in the rectum, and 
the rectal mucosa was covered with same, mixed with some light-brown 
fecal material. Small circinate lines and punctate ulcers were seen 
on the rectal walls and valves of Houston. A mild granular procto- 
sigmoiditis was noted. Microscopic examination revealed Entamceba 
histolytica, Trichomonas intestinalis, Paramwcia, and others. 

Diagnosis: amebic dysentery. 

Case 2. — Name, Dr. ; age, 53 years; race, white; occupation, 

physician; family history, negative; previous health, good, until 23 
years of age, since which time he has never been well. Symptoms: 
At the age of 23 suffered a very severe attack of dysentery, and for a 
long time, hope of recovery was despaired of. Later a change of climate 
seemed to contribute to his slow but apparent recovery. After return- 
ing home suffered a relapse. Since that time has suffered abatement 
and acceleration of symptoms; alternating attacks of diarrhea and con- 
stipation; suffering now from profound melancholia and insomnia with 
suicidal inclinations. Temperature, subnormal; pulse, 65; tongue, dry 
and coated heavily, round and thick; skin, inactive and muddy; liver, 
enlarged, extending three inches below costal border and tender, prob- 
ably the seat of a large abscess. Pain on pressure over entire course 
of colon, especially over cecum, hepatic and sigmoid flexures. Puruncu- 
losis (staphylococcic) over entire body; atonia gastrica with dilatation; 
kidneys, normal. 

Proctoscopy: rectal walls very much thickened, scarred, and stenosed, 
this last condition observed at rectosigmoidal juncture also; red granu- 
lar hypertrophic rectosigmoiditis. The characteristic ulcers, previously 
referred to, were found beneath a coating of offensive blood-tinged 
mucus, which was mixed with pus. Microscopic examination revealed 
large active phagocytic Amce'ba histolytica, colon bacilli. Trichomonas 
intestinalis, Cercomoyias intestinalis, and other symbiotic bodies in 
great numbers. The blood examination, made by Dr. Krauss in this 
case, shows the following: 3,940,000 red cells, 75 per cent hemoglobin, 
13,700 white cells, of which 74 per cent polynuclears and 3.3 per cent 
eosinophils. The opsonic index failed. The bacteria isolated from the 
pustules were staphylococcus alhus and a single colony of aureus. I 
regard the blood condition to be one of secondary anemia with mild 
coccus infection, and the moderate eosinophilia is probably due to the 
intestinal condition. 

The furuncles were healing nicely when I last saw the patient, and 
he expressed himself as feeling greatly improved. 

Diagnosis: amebic dysentery. 



DYSKNT^RY 233 

The author looks Avith suspicion upon any case of dysentery 
or diarrhea, recurring or relapsing, which has failed to re- 
spond promptly to treatment. 

Dysentery and diarrhea are not essential symptoms of the 
existence of amebiasis, though this is contrary to the generally 
accepted theory. In many cases the patient will complain of 
recurrent diarrhea which has existed for months or years. These 
attacks are accompanied by passages of mucus, usually con- 
siderable in quantity, and occasionally stained with blood. The 
patient complains of almost constant pain or discomfort in the 
left iliac fossa, and when the lower rectum is the seat of con- 
siderable ulceration, pain at the end of the spine and in the 
rectum is felt. This symptom is momentarily relieved by evac- 
uations. 

A case from the ^Mississippi Delta, reported by me to the 
American Proctologic Society, had most violent symptoms 
from the onset. On the fifth day a large slough of mucous mem- 
brane (Fig. 123) was passed en masse. Thirty-six hours later 
the patient died. 

]\Iost of the chronic cases will give a history of having lost 
much weight, perhaps twenty to fifty pounds. Many have symp- 
toms of interest to the stomach specialist, and to the neurolo- 
gist. 

Complications and Sequelae. — These are very numerous in- 
deed. 

Of 1537 cases of diarrhea in Egypt, only 406 were uncom- 
plicated. 

Hepatic abscesses were found in six out of eight autopsies by 
Councilman. In four of these they were multiple. 

Strong and Musgrave found hepatic abscesses in 14 out of 
97 cases. The author, as previously stated, found liver infec- 
tions in four out of twenty-five cases. 

The vermiform appendix has been found to be involved in 
fully ten per cent of chronic cases by the author. 

Among the other complications most frequently occurring 
are : perforations, extensive sloughs, hemorrhages, fibrosis of 
the valves of Houston, rectal stenosis, adenomata recti, chole- 
cystitis and jaundice, perirectal abscess, hemorrhoids, fistula, 
pneumonia, pulmonary abscess, pleurisy, bronchitis, nephritis, 



234 DisiiASEs o^ THE re;ctum 

portal thrombosis, cerebral and meningeal emboli, gastritis, atonia 
gastrica, melancholia, which is often profound, and in many of 
my cases more or less extensive skin lesions and nervous symp- 
toms have been observed. More especially have these compli- 
cations been seen in chronic cases, but these are considered of 
sufficient importance to deserve the following special mention: 

Dr. John L. Jelks' report: 

Skm and nervous manifestations and complications referahle to blood 
contamination and poisoning of the central nervous system, to which 
special allusion seems apropos. 

For the past five years the author has interested himself in the un- 
mistakable relationship between amebiasis and various skin and ner- 
vous manifestations of varying character and severity, and was the first 
writer to allude to these symptoms and complications in several mono- 
graphs written during these several years. 

Many of these manifestations are so vague as to escape other than the 
scrutinizing eye, and varying thus from this mild coccus infection or 
toxic manifestation above referred to, he has observed the most dis- 
tressing urticarial, erythematous, and desquamative dermatitis, and in 
the first part of April, 1910, the author presented before the Tennessee 
State Society a patient who was a well-defined pellagrin and who had 
suffered amebic infection for three years. 

The object, in referring to these manifestations, is to show the grave 
complications of this character, which may associate themselves with 
amebic ulceration and collateral infections. 

Case Report: Mr. A. R. C, age 40, American; occupation, lumber- 
man. Father living; health, good; age 71. Mother died of tuberculosis 
at the age of 36. 

About twenty years ago, the patient became overheated and began 
having indigestion, diarrhea, and dysentery. Fifteen years ago, suf- 
fered a very severe dysenteric attack. Again, five years ago patient 
began passing large quantities of mucus, which at times was mixed 
with blood and pus. 

His symptoms grew progressively worse, and on December 8, 1911, 
he was brought to me for examination. His emaciation was extreme 
and general condition bad. His blood picture denoted anemia and 
toxemia. 

Proctoscopy: The rectum and sigmoid were eroded and contained 
offensive mucus, blood, and pus. The typical amebic ulcers were 
curetted, and the material revealed large numbers of Amwha histolytica 
and symbiotic bodies. 

The amebse contained blood-corpuscles and blunt, rod-shaped, non- 
motile bacilli, distributed without order in great numbers. Colonic ir- 
rigations were begun and patient's diet restricted to albumin and 
buttermilk, but the patient's condition grew steadily worse. 



dyse:nte:ry 



235 



On December 21, 1911, appendico-cecostomy was performed, and ir- 
rigations were begun the following day. Improvement was noticeable, 
and a more liberal diet permitted, which was followed by a relapse and 
profound toxemia. In two days marked improvement again was noted, 
the result of persistent irrigations with large quantities of salt solu- 
tion and restrictions of diet. The appended illustration was taken at 
this time (Fig. 126). 




Fig-. 126. Photograph of case, Mr. A. R. C. 



He no longer passes mucus or blood; he is up from four to six hours 
each day. 

The case is one of amebiasis associated with the series of symptoms- 
complex, known as pellagra. 

The prognosis must appear grave indeed; yet, great improvement 
has resulted from the treatment. 



236 DI SILASES O]? THE RECTUM 

Dr. Marcus Haase's report: 

In regard to the patient I saw with you, Mr. A. R. C, at the City 
Hospital on December, 10, 1911, I find that I made the following record: 
There was an erytheraato-squamous condition on the backs of the hands, 
elbows, nose, the left side of the neck, and about the ankles. All of 
these lesions were sharply defined. In no instance gradually extending 
into the normal skin and were all of a distinctly pellagrous character, 
and I was at that time quite satisfied that the disease from which he 
was suffering was unquestionably pellagra. 

I saw this patient again on February 18, 1912, and at that time the 
lesions had entirely disappeared. The skin, while atrophic, was not 
as markedly so as I should have expected in a case of this severity. 
While we might expect all acute lesions to disappear in this length of 
time, I should expect to find an atrophic condition more marked than 
I found in this case. 

February 22. 1912. 

Dr. W. C. Sommerville's report: 

Mr. A. R. C. male, age 40 years. Five or six years ago began with 
weakness, especially in legs, and indigestion, a sensation of heaviness 
in gastric region. Has been unable to do a whole day's work during 
this period. Two years ago weakness of legs was more decided and has 
progressively increased since. Vertigo for past two or three years. 
Diplopia for past eighteen months. In September, 1911, had an erup- 
tion on backs of both hands, which had the appearance of sunburn. 
Says he has been sunburned several times. Does not know how long 
his limbs have been atrophied. 

Mental condition: Dull, memory bad, and rather irritable and de- 
pressed, answers slowly, and is unable to recall his symptoms with any 
degree of accuracy. Patient presents a condition of a very decided gen- 
eral emaciation, but in addition, there is more or less general mus- 
cular atrophy, especially marked in the small muscles of both hands, 
but involving to some extent almost the entire musculature. Pupils 
dilated but equal, and react to light and by accommodation. External 
ocular muscles negative. 

Diplopia and nystagmus present. Sensory branch of fifth nerve 
negative; some weakness and atrophy of muscles, supplied by motor 
branch. Slight weakness of facial muscles, hearing fairly good, and 
air conduction greater than bone conduction. No difficulty in swallow- 
ing. Movements of tongue weak, and tongue slightly atrophied. 

There is decided loss of power in all movements of the four extremi- 
ties, especially marked in small muscles of both hands, which are de- 
cidedly atrophic. There is no paresthesia, and no sensory disturbances 
of any kind, except tingling and numbness over anterior surfaces of 
both thighs, which show a hyperesthesia, and hypalgesia; slight ting- 
ling and numbness of hands and feet. Has poor control over sphincter 
of bladder. Slight incoordination manifested in making nose-finger 
test. 



dyse:ntkry 237 

No wrist-jerk was obtained, either right or left. Both elbow-jerks 
were brisk and equal. Both knee-jerks were brisk and equal. The 
ankle-jerks present and equal. The plantar reflexes were extensor, both 
right and left. External malleolar reflex not obtained. Abdominal re- 
flexes present. 

The symptoms, which this patient presents, indicate extensive de- 
generative changes in the cells of anterior horns and the motor nuclei; 
of some of the cranial nerves; and degeneration of the crossed pyramidal 
tracts; and beginning degeneration of the posterior columns of the cord. 

Statistics from all sources show that perhaps twenty per cent 
of all cases are complicated by hepatic infection. The right lobe 
is most often invoh'ed. The author believes this complication 
will appear less frequently in the future, owing to better diag- 
nostic facilities, care, and treatment by the internist. 

Perforations may occur along the course of the colon at any 
point between the rectum and appendix. Perforative appendi- 
citis has been noted. 

Perforations occurred in 85 out of 580 cases selected by Ber- 
anger and Feraud. 

Stenoses have been observed in a large per cent of chronic 
cases, usually in the rectum and sigmoid. AMien fibrosis of 
the rectal valves is observed, it is a grave obstacle to the com- 
plete cure, owing to interference with drainage and local treat- 
ment. 

Hemorrhoids, though frequently noted, are not serious com- 
plications as a rule. 

The other complications mentioned above should be borne 
in mind and treated when they occur. 

Diagnosis. — This is rendered easy b}^ means of the micro- 
scope, all doubt being removed by finding the Bntainoeba histoly- 
tica in the stools, or in the material curetted from the ulcers 
in the rectum and sigmoid. 

Prognosis. — The prognosis in amebic dysenter}^ is likewise 
much graver than in the acute catarrhal form. It may be said 
to depend upon several things : 

1. The previous state of health of the patient. 

2. The hygienic condition of the patient's surroundings. 

3. The efficiency of the treatment employed. 

In the United States the total number of deaths from all 



238 dise:asi;s o^ thic re:ctum 

forms of dysentery in 1850 was 20,556, a per cent of 6.32 of the 
total mortality. 

In 1880, out of 756,893 deaths, 10,825 were from dysentery. 

Treatment. — The treatment of dysentery will be discussed 
under the heads: (a) Prophylactic, (b) Dietetic, (c) Remedial 
and Operative. 

Prophylactic. — Strict attention should at all times be given 
to the hygienic condition of surroundings. Remove and avoid 
as far as possible the causes of dysentery. Cases should be iso- 
lated when it is possible to do so. All excreta should be care- 
fully disinfected and deposited where the water supply will not 
be contaminated. The country practitioner, living where there 
is no sewerage system, should never neglect to caution those 
attending the patient to deposit the excreta in a hole dug for 
the purpose as far removed from the water source and garden 
as possible, after first disinfecting thoroughly. 

If a person, knowing the danger, were to deposit the excreta 
of a dysenteric patient in a garden, it would be inexcusable. 
The author has, however, seen this done by some who had 
never suspected danger in so doing. In the country, and in 
small towns, without sewerage, small closets are usually found 
in or near the gardens, and are often made sources of fertiliz- 
ing material for the growth of vegetables. It is the duty of 
the physician to educate his patients in regard to all dangers 
resulting from such gross unsanitary practices. Wells and cis- 
terns are contaminated much more often than the average lay- 
man suspects. When the source of the drinking supply is at 
all questionable, the water should be boiled before drinking. 

Overcrowding and poor ventilation should be prevented. The 
care of the room occupied by the patient is important. Unneces- 
sary furniture, such as curtains, rugs, carpets, etc., should be 
removed. Disinfectants should be used at regular intervals. 
Linen should be changed daily. Bedpans, commodes, drinking 
cups, etc., should be disinfected thoroughly. 

DiivT. — Diet is as important as any other matter in the treat- 
ment of dysentery. During this period of acute intestinal symp- 
toms it should consist of buttermilk, whey, tgg whites, barley 
water, and perhaps one of the standard malted milk foods for 
infants. 



DYSENTERY 239 

In all cases select a diet which is digested as far as possible 
in the stomach, and which has little waste. Food is best given 
at intervals of one to two hours in acute cases. Plain sweet 
milk may be diluted with barley or rice water, lime water or 
Vichy, if imperfectly digested. 

In the bacillary form of dysentery and in those cases in which 
this form of infection is suspected of much part in the inflamma- 
tory process, milk in any form should be eliminated for a safe 
period of time, and the diet restricted to albumin, whey, bar- 
ley water, and abundant sterile water. In these cases animal 
broths are very liable to produce a rich media for the bacillary 
growth. 

While fruits in general are interdicted, the juices of oranges, 
lemons, and pineapples have not given particular disturbance in 
most cases in which they have been used, especially as palatable 
vehicles for albumins. 

During convalescence in all forms of dysentery and for chronic 
cases, the author prefers buttermilk, whey, and eggs. In some 
cases tender portions of turnip tops, mustard, spinach, and aspar- 
agus tips have been given, and were relished by the patient. 
It is, however, questionable as to the advisability of giving the 
patient much vegetable diet. 

In cases of amebic dysentery the author is especially partial 
to a diet of milk and tgg whites. The eggs may at times be 
prescribed in large quantities, from eight to fifteen per day. 
They can be ordered raw, mixed with milk, or in the form of 
fruit-albumin. The last is made by stirring the white of one 
egg into a glass half full of crushed ice, then flavor w^ith orange 
or other fruit juice. Diflrusible stimulants, such as champagne, 
sherry wine, or whiskey, may also be added to the egg mixture 
when cardiac weakness and adynamia are present. 

The albumin may also be mixed with sweet milk, or sweet 
milk with lime water in the form of a milk-shake, to which may 
be added the alcoholic stimulants, if no contraindications exist. 

Buttermilk is an especially favorite diet. Its acid properties 
make it desirable. 

The articles of diet which are contraindicated are all dishes 
highly seasoned with pepper, cinnamon, nutmeg, etc. Vegeta- 
bles, especially the raw varieties, pork, salt meats, veal and fish, 



240 DISE:ASKS 01^ THE Ri:CTUM 

saccharine foods, fried foods, nuts, oatmeal, and fruits, other 
than those mentioned, should also be interdicted. 

REme^dial. — The medicinal treatment of dysentery is a most 
interesting subject. A great number of so-called specifics, and 
much-praised remedies, have been handed down to us, but most 
of them have proved so unsatisfactory that it is no surprise 
that most of the present-day suggestions are greeted with a 
certain amount of skepticism or personal prejudice. The sys- 
temic treatment as a cure for dysentery is erroneous. It is a 
local disease and therefore requires local treatment. This is 
certainly true with reference to immediate pathology, but other 
remote pathological conditions may require constitutional treat- 
ment. 

The ameba is a very low form of organic life and is very 
easily killed or rendered inert. The fact remains, however, that 
the parasites are embedded in the tissues in such vast numbers 
as to make their destruction difficult. Certainly any chemical 
which is given by mouth, after passing through the stomach and 
small intestines, can possess little parasitic effect when it reaches 
the lower colon, sigmoid flexure, and rectum. Therefore, our 
chief reliance must be placed in local applications, which are 
used for the following purposes : namely, that of washing away 
the pus, mucus, and debris, and at the same time the amebse 
and other pathogenic organisms, also that of antisepticizing the 
bowel contents and walls, that the further growth and develop- 
ment of the pathogenic organisms will be inhibited. 

It is also important to remember that the remedies selected 
should be those which will destroy the greatest number of or- 
ganisms beneath the lining membrane of the bowel without de- 
struction to the tissues themselves. 

In the earlier stages of acute dysentery the patient should 
be put in bed, and absolute quiet enjoined. Chilling draughts 
of air are to be cautiously avoided, since they are apt to in- 
crease the congestion of blood toward the internal viscera. Bath- 
ing the patient with warm water, vinegar, or alcohol will often 
give great comfort by relieving the burning sensation in the skin. 
The perianal region should be sponged frequently with an anti- 
septic wash, such as a mild boric acid and formalin solution, 
and dusted with some mild antiseptic powder, as equal parts of 



DYSENTERY 241 

boracic acid and aristol. An ointment of similar composition 
may be used instead. Applications of hot or cold to the anal 
region will often relieve the burning and tenesmus in the lower 
rectum. The hot hip-baths also have been very helpful in re- 
lieving this condition. 

In the more severe cases the constant application of ice bags 
over the left iliac region gives comfort. Hot fomentations are 
sometimes to be preferred, but in the majority of cases, the ice 
bag is better. 

The severe griping and tormina are relieved quite readily 
by hot turpentine stupes or by large flaxseed-meal poultices. 
These may be used just as frequently and for as long a period 
as needed. 

Laxatives. — Occasionally absolute rest and strict diet are all 
that are needed to relieve the patient, but it is in most cases best 
to administer some mild laxative to remove the contents of the 
bowel, which acts as both a mechanical and chemical irritant. 

Castor-oil and magnesium sulphate, to the latter of which may 
be added dilute sulphuric acid, are the most popular remedies 
for this purpose. The salines, by their hydrogogic action, deplete 
the inflamed mucosa and wash away many of the infecting micro- 
organisms. It must be remembered, however, that all purgatives 
act as irritants to the intestinal mucous membrane in a greater 
or less degree, and their use must be guarded with judgment. 
In some cases they would be harmful. If there has been much 
diarrhea and the stools are copious and thin, purg'atives are 
contraindicated. 

When to repeat a purgative is another question that should be 
considered with care. Often much harm is done in this way. 

Calomel, or calomel with ipecac, is often ordered in small 
doses for a dry, furred tongue, and inactive liver with foamy 
acrid discharges. Our aim in giving calomel is not only that 
of producing the antiseptic action of bile, but also, by deplet- 
ing the liver, of relieving the portal congestion; and this, in 
turn, the congestion of the veins about the rectum. The se- 
vere griping pains and tenesmus, the diarrhea, and restless 
condition of the patient, when present, must be relieved, or the 
outcome will be rapidly adverse. Opium is the remedy, either 
in the form of Dover's powders, paregoric, laudanum, or mor- 



242 dise:asks 01^ the rectum 

phin. This last is no doubt the most popular form of the 
drug and is best used hypodermatically. The dose should be just 
large enough to keep the patient quiet and to relieve the suf- 
f erring, but never sufficient to produce narcotism. 

It must not be forgotten that opium may do great harm in 
some instances. If nature is attempting to throw off the putrid 
contents of the bowel in large, liquid stools, we should not 
give opium, for in doing so we are interfering with her efforts 
to relieve the condition. 

A large number of intestinal antiseptics have been given in- 
ternally for dysentery, the principal ones being calomel, lead 
acetate, zinc sulphocarbolate (in one-half to three-grain doses), 
salol, guaiacol carbonate, bichlorid of mercury (dose, grains 
■K20 to %0' 3-i^<i acetozone. These are all, however, given 
by the author with a feeling of uncertainty. 

Those cases which begin with symptoms of cholera morbus, 
with nausea and vomiting, and subnormal temperature, call for 
hypodermic injections of morphin sulphate, gr. ]4,, and atropin 
sulphate, gr. /boo- ^'^ control nausea, may be given carbolic 
acid and tincture of iodin, each one minim, well diluted, by 
mouth. This is followed by calomel, gr. ^-^, and salol, grs. 2 
to 5, with just a sufficient amount of hot water to administer 
same. In many cases of nausea the ideal treatment is that of 
stomach lavage, using very hot water, to which is added oil 
of cloves one-half to one dram per quart and briskly agitated. 

In other cases cocain hydrochlorate (gr. Y^-Yz) , or chlore- 
tone (grs. 5-15) may be given. Where there is much depres- 
sion, warm enemata of normal salt solution may be given, or 
this may be given by hypodermoclysis. The effect is a dilu- 
tion of the toxins and a reaction. A mustard plaster or hot 
turpentin.e stupe over the epigastrium is beneficial in these 
cases. If the temperature and pulse *are not subnormal, the 
tormina, tenesmus, and burning can be allayed by enemata of 
cold water, the temperature of which should be regulated to 
suit the case. 

When there is marked irritability of the rectum, the follow- 
ing suppository should be inserted before injections are made: 



dysenti:ry 243 

I^ Cocainas hydrochloridi 

Extract! stramonii 

Extract! belladonnse aa gr. ss 

Ole! theobramatis q. s. 

Misce et fiat suppos!tor!a, No. 1. 
S!g. : Hold the suppository in the anal canal about one minute 
then press into the rectum with the index finger. 

Kartulis claims that he found ipecacuanha to have an ahuost 
specific influence upon dysentery. 

His method of administering this drug was to give a one- 
half -grain injection of morphin hypodermatically and place a 
mustard plaster or turpentine stupe over the epigastrium. After 
half an hour twenty grains of pulv. ipecac were given, and this 
dose was repeated every half hour to one hour, until an ounce 
had been given. 

Another method of giving this drug: Put 2 to 8 grams (^ 
to 2 drams) in 500 grams (1 pint) of water and let stand two 
hours. This sohition is filtered off and constitutes the first 
dose, or this is at times divided into two or more doses. Ac- 
cording to Kartulis, this always produces emesis and diarrhea, 
but after a second or third infusion, which is made from the 
remaining portion of the powder with the same quantity of 
water, has been taken, the vomiting and purging become less 
frequent. 

If, after the third days' treatment with these infusions, the 
patient has not improved, another series of infusions with a 
fresh supply of ipecac should be given. 

The author has mentioned this treatment only to condemn it. 
It has been known to produce death, and does not cure the dis- 
ease. According to some authors, there is no reason for dys- 
entery existing in the same world with ipecac and that this drug 
will even abolish an established abscess of the liver. Such is one 
of the curiosities of the statistics found in a recent article 
by McDill. I have administered large doses of ipecac daily 
for a week, then found the living amebae in the bowel scrapings 
as if undisturbed by the drug. In all cases it is a cardiac de- 
pressant and lowers the physical resistance of the patient. It 
is a violent intestinal irritant. The powdered drug has also 
been found impacted in fatal perforating ulcers of the bowel. 
To my mind, therefore, its administration in this disease, by 
this method, is dangerotis, adding insult to injury. 



244 DiSEjASKs 0^ the: rectum 

For the acute catarrhal type the elimination of irritating sub- 
stances and free exosmosis, obtainable by the administration of 
epsom salts, and enjoined rest in bed, with abstinence from all 
but the blandest forms of diet, will often suffice. In these cases, 
however, the injection of tepid water, containing to each quart, 
minims x to xx of formalin, and one tablespoonful of boric 
acid, may be necessary. This is often followed by the same 
quantity of cold water, or by the injection of 1 or 2 ounces 
of olive oil and one scruple of bismuth subnitrate. These in- 
jections can do no harm and are surely destructive to the life 
and propagation and pathogenic properties of the infecting 
agents. 

If the symptoms do not abate, and the patient does not ob- 
tain marked relief within the first few days from the use of 
the above-described treatments, pathologic conditions may be 
present which may require other forms of local treatment in 
the nature of topical applications. 

A subacute catarrhal condition may supervene in which an 
astringent and antiseptic treatment will be required to complete 
the cure. For this purpose may be used the injection of a tannic 
acid solution, one dram to a pint of water, followed by the 
introduction of a suppository containing : 

I^ Extract! belladonnse gr. ss 

Extract! stramon!! gr. ss 

Thymolis !od!d! gr. v 

Ole! theobromat!s q. s. 

Misce et fiat suppositor!a No. 1. 

Or the following ointment : 

I^ Extract! belladonnae gr. ss 

Extract! stramoui! gr. ss 

ThymoHs iod!di gr. v 

Petrolat! l!qu!d! q. s. 
Misce et fiat imguentum. 

If the disease assumes one of the more virulent types, and 
if the ulceration is extensive, still more radical measures should 
be sought in the high irrigation with the formalin-boric solu- 
tions. These, if possible, should be given through a recurrent 
tube (Fig. 127), since by this means only can a large quantity 
of the solution be used without distending the inflamed and 
ulcerated bowel to a painful or perhaps dangerous degree. 



dysente:ry 245 

Four to eight quarts of this sohition are usually required for 
one irrigation. 

Some authorities are partial to the use of quinin solutions 
(1:5000 to 1:500) in cases of amebic infections. Among the 
advocates of this drug are ^lusgrave and Strong, and Osier. 
H. F. Harris, of Atlanta, says : "I used this treatment with 
great persistence in some of my earliest cases, but not in a 
single instance was there the slightest perceptible result. In- 
jections of 1:100 to 1:300 watery solution of bisulphate of 
quinin were somewhat beneficial in one or two instances." 




Fig. 127. The Jelks soft-rubber recurrent recto-colonic irrig-ating 
tube. — Courtesy of Dutro and Hewitt, Memphis, Tenn. 

My own experience with these injections is in accord with 
that of Dr. Harris. 

Hanes, of Louisville, treats these amebic infections of the 
colon with kerosene oil; the oil is poured into the colon while 
the patient is inverted. 

The use of formalin solutions in the strength of 1 :500 to 
1 :1000 has in the author's hands afforded the best results. 

My study of the effects of this chemical has extended over a 
period of 12 years. I have relied not only upon clinical results 



246 dise:ases 01^ the: re:ctum 

obtained, but also upon the microscopical observations in demon- 
strating the efficiency of formalin. After only one or two in- 
jections with these solutions, I have been unable to find any 
living organisms in the bowels for hours afterward. This, it 
wa-s observed, was not the case when other solutions were used. 

Rapid healing of the ulcers was always noted while continuing 
the irrigations of the formalin in the above-mentioned strengths. 

To be certain of the effect of this drug, its use was discon- 
tinued for the time being, and such irrigations as plain water 
(warm or iced), normal salt, and quinin solutions were sub- 
stituted. In every instance the ulcers reformed, and both amebse 
and bacteria of symbiosis were found again in the miscroscopical 
examinations. Upon returning, however, to the formalin irri- 
gations, these micro-organisms disappeared, and the ulcers be- 
gan the process of repair. Thus the author has concluded that 
this chemical, judiciously used, is really the most effective in 
the destruction of the amebas and associated organisms, and 
most valuable in the treatment of dysentery. 

During the past two years I have been giving iodin and 
thymol, internally, with gratifying results. The latter is es- 
pecially valuable in that it destroys not only the amebae but 
other intestinal parasites. I find solutions of iodin and of 
thymol of especial value when used as colonic irrigations. This 
method appeals to me most when the solutions can be applied 
through the cecum. 

Seven grains of thymol dissolved in a pint of water, and 
filtered, give a solution whose strength is approximately 1:1000. 
A solution of this strength may safely be used in irrigating the 
colon through the cecostomy opening. This solution should be 
followed by a solution of magnesium sulphate or sterile water. 
Thymol solutions thus used are analgesic and may relieve the 
distressing neuralgic pains and tormina in the colon. Relief of 
these unpleasant symptoms may also be given by the use of 
chloretone solutions. The injection of olive oil and bismuth 
almost instantly relieves the painful effects of these solutions. 

The dangers of overdistention of an inflamed and ulcerated 
colon are difficult to overestimate. To avoid this, the author 
has devised a double or recurrent colon tube, made of soft 
rubber, and constructed in such manner as to facilitate its 



dysknte;ry 



247 



introduction through the rectum and into the sigmoid. The 
tube having been properly inserted, it is an easy matter to 
change the position of the patient, and by so doing irrigate 
the entire colon (Fig. 128). 

In some instances the tube is obstructed by the rectal or 
rectosigmoidal valves, which may necessitate its introduction 
through the sigmoidoscope or proctoscope. In chronic cases 
especially has this difficulty been encountered, since in these a 
fibrinous infiltration of these structures often exists, rendering 



1. 




'A 


K. 




} ^ 


1 


1 











Fig". 128. Exaggerated Sims' position, showing method of high irri- 
gation of colon through Jell^s' recurrent tube. 



almost impossible the use of an ordinary rectal tube. To ascer- 
tain whether or not the tube had coiled in the rectum, the oper- 
ator can introduce the index finger, well anointed, with the lubri- 
cant given below. After several unsuccessful attempts have been 
made, the proctoscope should be introduced and the tube inserted 
through it, as shown in Fig. 129. 

A lubricant of the following formula is preferred by the 
author : 



248 disi:ase:s of the rectum 

I^ Pulveris tragacanthae gr. ccclxxxiv 

Phenolis m ccxl 

Glycerini Sij 

Aquae destillatae q. s. ad Oij 

Misce. 
Shake up gum with enough alcohol to make thick paste. Add acid 
and glycerin. Shake well and add water all at once. Agitate vig- 
orously. 

Dr. Louis LeRoy, of Memphis, has suggested the use of 
phenolsulphonate of copper solutions for the colon irrigations. 

The author has used this chemical in the treatment of a num- 
ber of cases, but is unable to state its exact degree of efficiency. 
It is a very powerftil parasiticide, and its use is advised alter- 
nately with the formalin-boric solution. The strength of the 
copper solutions is 8 to 10 grains to each quart of sterile water. 

Ichthyol (10 per cent solution) applied locally to the mucous 
membrane, or gauze, saturated with the same solution, packed 
in the rectum, has seemed to exert a beneficial effect. 

It is well to mention here that an antidysenteric serum has 
been very highly recommended in the treatment of the malignant 
bacillary type of dysentery. 

My recent experience justifies the mention of mixed vaccines 
(Van Cott) in some of the chronic cases, with skin infections 
and associated furunculosis and pruritus, or of the autogenous 
bacterins, as advised by Murray, of Syracuse, who has made 
an exhatistive study of the bacteriology in some such cases. 

CHRONIC OR SECONDARY AMEBIC DYSENTERY. 

All subacute or chronic cases of dysentery depend for their 
symptoms upon an ulcerated and inflamed condition which will 
not yield to treatment. 

These cases have exacerbations and amelioration of symptoms. 
They often complain of constipation, which may extend through 
a period of weeks or even months. It is in these subacute and 
chronic cases that the proctologist is most often consulted. 

Such remedies as nitrate of silver, grains 30 to 60 to an 
ounce of sterile water, or a 20 per cent solution of argyrol, are 
applied, after first cleansing and antisepticizing the rectum and 
sigmoid with pledgets of cotton wrung out of hot formalin-boric 
solution (Fig. 130). 



DYSENTERY 



249 



A 30 per cent solution of lactic acid has also been used to 
cauterize the ulcerative areas. 

After these applications have been made, the bowel is sprayed 




Fig. 129. Position of patient for proctoscopy. Proctoscope intro- 
duced to facilitate the introduction of the colon tube. 

with some neutral or alkaline solution to neutralize the excess 
of the silver or other solution used (Fig. 131). 

The bowel surfaces are then dried. Now, the insufflation of 



250 



dise:ases 01^ the: rectum 



some non-toxic antiseptic powder, such as equal parts of boric 
acid and aristol, is advised. 

The symptom of iodism is an unpleasant one and may be 




Fig-. 130. Method of application of silver and other solutions to 
the ulcerated surfaces of the rectum and sigmoid. 



readily produced by the instillation of drugs containing iodin 
into the rectum. Because of this, these remedies, such as aristol, 



dyse:nte:ry 



251 



bismuth- formic-iodid, and iodoform, have appeared most effec- 
tual when used just to the point of tolerance. 

When the amebic infection has become very chronic, or has 




Fig. 131. Method of spraying- rectum and sig'moid with solutions, 
and also of insufflating- mucous surfaces -with antiseptic po-v\'ders. 



extended into all parts of the colon beyond the use of the local 
measures just described, appendico-cecostomy should be per- 



252 dise:ase:s of the rectum 

formed, and the same fluids previously suggested should be used 
in irrigating, through the appendico-cecostomy opening. The 
fluid is allowed to pass out through the rectum into the catch 
basin, or a drainage tube may be inserted into the rectum. 

This plan of treatment was first advised by Dr. E. A. Cor- 
sons, of Savannah, Ga. 

In 1898, Dr. H. F. Harris stated that some years before Dr. 
Corsons made this suggestion to him. Irrigations of the 
bowel with hydrogen peroxid through the artificial opening, 
thus established, were also advised. 

About the year 1901, Dr. Robert Weir, of New York, while 
performing a colostomy for amebic dysentery, anchored the 
appendix and irrigated through the stump with a saline solu- 
tion. 

Shortly afterward, Dr. Meyer, also of New York, performed 
a similar operation. 

Dr. Tuttle, of New York, conceived the plan of allowing the 
appendix to remain undisturbed after anchorage for a sufficient 
time (three or four days) to establish adhesions about the 
proximal end before cutting away the distal portion, and using 
the appendiceal stump lumen through which to irrigate with 
the desired solutions. 

The author has practiced this last method and irrigated the 
colon with formalin-boric, copper phenolsulphonate, quinin, and 
iodin and thymol solutions with most gratifying results. It 
was observed, however, that the irrigations alone did not effect 
a cure. Topical applications (through sigmoidoscope or procto- 
scope) were in all cases used in conjunction. 

The technic developed by the author combines the appendi- 
costomy and cecostomy, and virtually makes an appendico-ce- 
costomy. 

The mesoappendix is ligated below the distal branch of the 
appendiceal artery ; then the appendix is brought through a 
small stab wound about one inch above the anterior superior 
spine of the ileum, as advocated by Doctor J. A. Crisler, of 
Memphis, in 1906. 

The exact location of the stab wound is determined by the 
position of the head of the cecum, and the possible tension when 
the patient is in the erect posture. The author's technic in- 



dysi'NTe:ry 253 

volves the anchorage of the cecum, not the appendix, but leaves 
the stump of the latter through which the irrigations are prac- 
ticed, avoiding pressure upon the same. The appendix may be 
immediately cut off, but to minimize the danger of infection 
I think it advisable to leave the same undisturbed for the 
first twenty-four or thirty-six hours, provided, of course, that 
no contraindications exist. 

When this operation is completed, I insert a small sterile 
catheter to insure continued patulency and at the same time act 
as a dilator. The appendicostomy-tube, devised by Dr. Hirsch- 
man. later replaces the catheter for permanent use in irrigating. 

In a few cases the author was forced to perform rectal 
valvotomies on account of obstruction to drainage, and to the 
insertion of the proctoscope or even the tube beyond the valves 
which were tightly stretched across the lumen of the rectum. 
This operation will rarely be found necessary. 

The author here wishes to acknowledge with thanks valuable 
assistance rendered by Dr. O. C. Fleumer in the preparation 
of this chaDter. 



CHAPTER XIV. 
PROLAPSE OF THE RECTUM IN CHILDREN. 

Prolapse of the rectum is the descent, with or without pro- 
trusion, of one or all of the coats of the rectum, uncomplicated 
by any other diseased condition. Prolapse of the anus is us- 
ually understood to mean the descent and protrusion of either 
the mucous membrane alone or all of the coats of the anus and 
lower end of the rectum outside the anal aperture. 

Prolapse may be either partial or complete. Partial prolapse 
is the condition in which the mucous membrane alone protrudes, 
complete prolapse describing the descent of all of the coats of 
the rectum. The complete variety is divided into three varieties, 
according to the degree or extent of the prolapse. 

Prolapse of the first degree is the condition in which the 
prolapsed portion begins at the anal margin, and the mucous 
membrane covering it can be seen to be continuous with the 
surrounding skin, there being' no sulcus surrounding it. In 
complete prolapse of the second degree, it will be found that 
the descent begins at some point in the rectum above the sphinc- 
ter and is extruded through the anal orifice, being telescoped, 
as is were, through the non-affected portion below. In this 
variety a distinct sulcus can be made out between the pro- 
lapse and the margin of the anus. 

Prolapse of the third degree may begin in the upper 
portion of the rectum, or even the lower portion of the sig- 
moid, may descend into the lower rectal cavity, but as a rule 
does not protrude from the anus. This variety is also known as 
concealed prolapse (Fig. 132). 

Inasmuch as the limitations of this work do not include those 
conditions whose relief requires surgical operations under gen- 
eral anesthesia, none of the conditions mentioned above 
will be treated, save the condition most commonly seen by 
the general practitioner — prolapse of the anus and rectum in 
children. The most frequent variety seen in children is that 
known as the partial or incomplete, and it consists of an ever- 

254 



pROivAPSE OF the: Rectum in children 



255 



sion of the anal canal, carrying with it the mucous membrane 
covering the lower end of the rectum. It is a condition amen- 
able in the vast majority of cases to non-surgical measures, 
when seen early and treated with patience and persistence. 

ETIOLOGY. 

It is brought about most frequently by severe prolonged or 



^^t 


liT 


\ 


i i 


^^R^^RH i-. 


1 
\ 

1 


1 


Wl 




1 


TJ 


/ 


^- .UBI*""**"^ 


^^^''^^^MWpi 


W^ . 



Fig-. 132. Prolapse of the rectum, third degree. This shows the 
prolapsing- rectum descending to the anus but not protruding. 

undue straining efforts on the part of the child. Such diseased 
conditions as the presence of a rectal polypus, hemorrhoids, 
foreign body in the rectum, hard constipated stools, pinworms, 
stone in the bladder, phimosis, diarrhea, excessive coughing or 
sneezing, accompanied by weakness of the sphincter muscle, are 
responsible at times ; but most common of all are the prolonged 
straining eft'orts at defecation. 



256 dise:ase:s of rut ri:ctum 

The practice so commonly in vogue among mothers in their 
efforts to train their children to regular habits of defecation 
has been responsible in the majority of cases for the production 
of prolapse of the rectum. The little patient is placed upon the 
toilet vessel or chair, and is soon made to realize what is expected 
of him. Sitting in the semi-squatting position, which is most 
conducive to the emptying of the rectum, even of its own mu- 
cous membrane, for half an hour, or even all the morning (as 
has happened in some cases which have come under the au- 
thor's notice), the little one using all his efforts in order to ac- 
complish his daily duty, gradually brings about a separation 
of the mucous membrane of the rectum, with accompanying 
protrusion from the anus. 

In other cases, through extraordinary efforts of the abdominal 
muscles, the mesentery of the sigmoid becomes elongated, and 
an intussusception of the upper rectum and lower sigmoid takes 
place. Protrusion of the prolapsed bowel is very rare in this 
instance, and a condition known as concealed prolapse is pro- 
duced and often goes undiagnosed for a considerable period of 
imie. From an anatomical point of view, the straightness of the 
sacrum in children offers less support to the rectum than in 
adults, and in children who have been suffering from wasting 
diseases, the parts become so relaxed that practically all support 
is taken away from the rectum. 

SYMPTOMS. 

When the rectum prolapses in children, it appears rather unex- 
pectedly. After a more or less long period of time, in which the 
''training" of the child has been going on, the mother is sur- 
prised, some fine day, by the appearance of a ring of red or 
purple-hued membrane surrounding the anus, the size depend- 
ing upon the amount of rectum prolapsed. The longer the 
prolapse remains outside the rectum, the more purple-hued it 
becomes from the interference with the return circulation on 
account of the contraction of the sphincter. 

DIAGNOSIS. 

The diagnosis is very simple, in fact, self-evident. The ap- 
pearance of a ring of soft, velvety mucous membrane protrud- 



PROIvAPSK OF the: rectum IN CHILDREN 257 

ing from the anus is indicative of only one condition, that of 
prolapse. A polypus would be differentiated by its rounded 
form, harder consistency, and the presence of a pedicle ex- 
tending inside the anus. Hemorrhoids, which are rare in children, 
would be gradual in onset, of firmer consistency, forming sepa- 
rate masses, and would not exhibit the peculiar red or purplish 
appearance of prolapsed mucous membrane. On each successive 
occasion, when the bowel is protruded, more of the mucous mem- 
brane comes down, and in aggravated cases the entire rectum 
may be extruded. 

TREATMENT. 

When the protrusion first makes its appearance it may be 
reduced in the following manner : The child is placed on its 
mother's lap with the buttocks raised considerably higher than 
the head. A compress soaked in ice water placed against the 
prolapse will often be all that is necessary. Gentle pressure will 
in a few minutes, in most cases, cause a return of the pro- 
lapsed portion. Oftentimes simple digital pressure on one side 
of the prolapse while the buttocks are separated with one hand, 
and steady pressure made with the fingers of the other, will 
suffice. The other half is then treated in like manner. 

Where the prolapse has remained outside long enough to 
become swollen, edematous, or congested, and the sphincter has 
contracted upon it, it will often be very difficult to return the 
prolapse unless the sphincter has been relaxed by the injection 
of a local anesthetic. In order to relieve the congestion and 
shrink the blood-vessels, the employment of compresses, soaked 
v/ith one to one thousand solution of adrenalin chlorid and ap- 
plied with firm pressure to the protrusion, has, in the author's 
hands, been found extremely satisfactory. The blood-vessels 
become constringed and the mass much reduced in size, and 
reduction is comparatively easy. 

Whenever pressure is used in this region, it should be firm 
but gentle, as it would be very easy to do serious damage if 
the manipulations were rough or violent. Wrapping dry ab- 
sorbent cotton around the index finger, and pressing firmly 
against the prolapse and in the direction of the rectal canal 
will often return a prolapse with ease. The finger is withdrawn 



258 DISEASES O]^ THE RECTUM 

in a twisting manner so as to allow the cotton to remain in 
the rectum, from whence it is expelled with the next stool. 

If the child's habits are corrected, the bowel, in many cases, 
will not protrude again. In cases, however, where the protru- 
sion recurs, a definite line of treatment must be undertaken 
in order to relieve the tendency to chronicity of the condition. 
Any exciting cause, such as stone in the bladder, phimosis, pin- 
worms, polypus, foreign body in the rectum, etc., must be re- 
lieved by proper surgical measures. If the case is due to 
constipation, the child's dietary should be looked into and cor- 
rected. 

Where the case is one, however, where the prolapse has been 
brought upon by the prolonged sitting at stool, with its coinci- 
dent severe straining efforts, this method of training must be 
dispensed with. The child must be made to move its bowels 
in the recumbent position, either lying on its back or side, pref- 
erably the latter. It must not be allowed to have movements 
in the sitting posture while under treatm.ent. The administra- 
tion of white petroleum oil or liquid albolene suitably flavored, 
in doses varying from ten minims four times a day in an infant, 
to a teaspoonful for the child of five or six years of age, should 
be resorted to in order to keep the stools soft and the intes- 
tinal canal well lubricated. It is important after the bowel 
movements to strap the buttocks together with strips of adhe- 
sive plaster, and in some cases it may be advisable to keep a 
pad made of absorbent cotton, wrapped with gauze, firmly against 
the anus. 

This treatment will be very successful if persisted in long 
enough. The author would advise two months as the average 
length of treatment in the average case. Any tendency to- 
ward diarrhea should be immediately looked after, and the 
dietetic cause for it discovered and corrected, for the violent 
peristalsis which accompanies diarrhea is often productive of 
as bad, if not worse, results as the straining efforts of con- 
stipation. 

Concealed Prolapse. — In some cases of constipation, so 
called,, in infants, all efforts for successful treatment will fail, 
and the author would advise in these cases the examination of 
the infant's rectum by means of a small-sized proctoscope or 



PROLAPSE OF THE RECTUM IX CHILDREX 259 

a large female cystoscope. Occasionally, this method of exam- 
ination will be rewarded by the discovery of a prolapse of the 
third degree (Fig. 132). which extends down to the rectum but 
does not protrude. In these cases the infant will be very fussy 
and will strain until red in the face, but all that rewards his 
efforts will be a small quantity of mucus stained with fecal 
matter: and the only way in which the child's bowels can be 
emptied is by means of enemata. The same treatment as 
outlined for the incomplete prolapse is indicated in this con- 
dition. 

The principal point in the prevention and the treatment 
of prolapse of the rectum in children is the education of mothers 
along the line of the so-called training of infants. While it is 
not the province of this work to go into the subject of infant 
feeding, nevertheless, the author feels that if more attention 
is paid to the presence of stifficient hydrocarbon elements in 
the child's dietary, and the child is made to drink sufficient 
water, much good would result. Instead of forcing the little 
one to sit upon the toilet seat from half an hour to an hour 
and a half, or even longer, the child's bowels would then move 
with regularity and ease, and prolapse would become a very 
rare condition. The squatting posture as assumed by the abo- 
rigines is the best for the children. If after ten or fifteen min- 
utes at the stool the child does not have a movement, it is 
far better to insert a soap suppository or administer a small 
enema to tide it over occasionally than to indulge in the per- 
nicious custom, seemingly so prevalent, of keeping the child 
on the seat for a prolonged period. 

AMien. in spite of strapping and the proper control of the 
bowel movements, the prolapse still persists, it becomes necessary 
to do something- more radical. The method which has been 
most satisfactory in the hands of the author, and which is par- 
ticularly adaptable to prolapse of the rectum in children, is 
what is known as linear cauterization. This may be accomplished 
in two ways — either by application of strong nitric acid or the 
use of the actual cautery. Xeither method is applicable with en- 
tire satisfaction unless a general anesthetic is employed. Xi- 
trous oxid. with or without oxvo^en. however, can be used in 



260 



dise:ases o^ the rectum 



these cases with perfect safety and makes a very dependable 
and satisfactory anesthetic. 

Cauterization by Nitric Acid.— The child is placed in the 
lithotomy position with the prolapse unreduced, and is placed 
under the influence of the nitrous oxid gas. The protruding 
mucous membrane is wiped dry, and a AA^ooden applicator, 
one end of which has been wrapped with a very small quan- 
tity of absorbent cotton moistened with fuming nitric acid, 
is all that is necessary. The acid is applied in 4 to 6 radiat- 




Fig-. 133. Prolapse of the rectum, first degree, showing- radiating- 
lines of cauterization. 



ing lines (Fig. 133), beginning at the uppermost portion of 
the center of the prolapsed mucous membrane at the lumen of 
the bowel, and with considerable pressure a line is drawn or 
painted to, but not touching, the mucocutaneous juncture. Four 
to six equidistant cauterizations are made in this manner, and 
an ointment composed of a dram of bicarbonate of soda to an 
ounce of petrolatum freely applied. A piece of rubber drainage 
tube, the size of a lead pencil, wrapped with gauze until it forms 
a plug or packing about ^ of an inch in diameter in its center and 



prolapse: of the rectum in children 261 

tapering at its extremities, is used to force the prolapse back 
into the rectum, and is left there for three or four days if 
possible. The little patient's suffering after the operation is 
not very acute, but if there should be much pain, it should be 
controlled by suitable doses of codein hypodermically ; ]4, to % 
grains of codein will answer very nicely in children from 5^ 
to 3 years old. 

The after-treatment consists in the same methods and pro- 
cedures as those advocated above in regard to diet, defecation 
in the recumbent position, the strapping of the buttocks, etc. 
After three weeks the child may be allowed to resume defeca- 
tions in the squatting position. In the first dressing immediately 
after the operation, it is wise to exert some pressure against 
the anus, by means of a suitable pad kept in place by adhesive- 
plaster straps. 

Linear Cauterization with the Actual Cautery. — The patient 
is prepared as described in the preceding paragraph, and when 
the prolapse is protruding to its fullest extent, a Paquelin cau- 
tery, armed with a blunt point, and heated to a white heat, is 
used for making the cauterization in the same manner as the 
nitric acid is used (Fig. 133V One should be careful to carry 
the cauterization through the mucous membrane and into the 
muscular layer, but should be extremely cautious about burn- 
ing through the muscular tissue. The amount of destruction 
of tissue is more apparent than real ; one must remember the 
object of the cauterization is to accomplish the contraction of 
redundant tissues, and it is the contracting scar which invari- 
ably follows the use of the cautery, upon which we depend to 
accomplish the results. In this condition zve take advantage 
of the great contraindication to the use of the actual cautery 
in the surgery of the rectum, for zve zuell knozu that the scar pro- 
duced by a burn on mucous membrane hirariably contracts to 
such an extent as to lessen the caliber of the rectum. The 
after-treatment, dressing, and packing are the same as described 
where the nitric acid is used as a cauterizing agent. 

Where these methods fail, there is nothing left to do but one 
of the cutting operations under surgical anesthesia, and prefera- 



262 DISl^ASES 01^ THE Ri:CTUM 

bly in hospital surroundings. When such is the case, the opera- 
tion had best be done by one who is specially trained in this 
line of work, and not by the general practitioner, as the opera- 
tive and after-care often taxes the patience, skill, and ingenuity 
of even the trained specialist to accomplish the desired results. 



CHAPTER XV. 

TECHNIC OF THE USE OF LOCAL ANESTHESIA IN 
THE TREATMENT OF ANORECTAL DISEASES. 
If any excuse or apology were necessary for the presentation 
of this work to the profession at this time, the subject matter 
contained in this chapter will be ample justification. The dan- 
gers, inconveniences, necessary confinement in bed, and de- 
tention from business, which must attend the use of general 
anesthesia in many so-called minor operations, have created a 
demand and constantly enlarging field for the use, in many 
departments of surgery, of local anesthetics. In the surgical 
treatment of diseases of the rectum and anus this is especially 
true; and while there are many diseased conditions of this re- 
gion recjuiring surgical interference, the extent of which makes 
their operative treatment impossible without general anesthesia, 
there are, nevertheless, many of the more common diseases of 
this part of the body which are entirely amenable to surgical 
treatment under regional anesthesia. 

The development of the use of local anesthesia in the treat- 
ment of anal and rectal diseases has progressed to such a stage, 
that it is safe to say that fully 75 per cent of all cases of rectal 
and anal diseases are amenable to treatment without the use of 
general anesthetics. 

ANESTHETIC AGENTS. 

Various anesthetic agents have been employed for the produc- 
tion of local anesthesia in this region, among which may be 
named the ethyl chlorid spray, and the injection of solutions 
containing quinin and urea hydrochlorid, cocain hydrochlorid, 
beta-eucain hydrochlorate and lactate, alypin, stovain, novo- 
cain, chloretone, as well as plain sterilized water. 

Formerly, cocain, in solutions varying in strength from 4 to 
10 per cent, was used. Symptoms of an alarming nature fre- 
quently developed after the injection of but a few drops of even 
a 4 per cent solution, which clearly demonstrated the toxic prop- 

263 



264 dise:ase:s 01? thi: rectum 

erties of the drug and the dangers of its indiscriminate use in 
strong solutions. Today we know that the extent of anes- 
thesia produced depends, not so much on the strength of the 
solution, as upon the pressure anesthesia produced on the nerve- 
endings, by the amount of solution injected, rather than its 
strength. 

Today, therefore, practitioners who are still partial to co- 
cain are using solutions for injection, varying in strength from 
YiQ per cent up to ^ per cent, and find the latter strength 
equal to the severest test. The author, after a trial of all of 
the anesthetics mentioned above, places his main reliance on 
beta-eucain lactate for skin anesthesia, and 1 per cent solution 
of quinin and urea hydrochlorid for infiltration of the tissues to 
be incised or removed. The lactate of beta-eucain is used in 
preference to the hydrochlorate, because of the fact that solu- 
tions of the former salt can be sterilized by boiling without 
detriment. 

The strength of the eucain solution varies according to the 
part to be anesthetized as well as on the amount of work to be 
done. For injection into the skin and for the anesthetization of 
the sphincterian nerves, % per cent solution is strong enough. 
For the distention of the tissues, for instance, in operating for 
fissure or internal hemorrhoids, a %o per cent solution will 
suffice. Another important reason for my preference for eu- 
cain is the fact that eucain is less than one-half as toxic as co- 
cain, and is fully as powerful in its anesthetic properties. 

My reasons for the increased use of quinin and urea hydro- 
chlorid are that, in addition to its equality to cocain and eucain 
as an anesthetic, it is non-toxic, can be sterilized, and its anes- 
thesia is prolonged for from two hours to several days after 
operation. 

Quinin and urea hydrochlorid is a double salt of quinin and 
urea, made by dissolving quinin hydrochlorid in hydrochloric 
acid, adding pure urea, filtering the mixture through glass 
wool, and allowing it to crystallize. It is soluble in its own 
weight of water and in alcohol. It has the action of quinin, is 
non-irritating when injected hypodermatically, and produces local 
anesthesia, lasting in some instances several days, depending 
on the strength of the solution. 



Te;CHNIC 01? LOCAI, ANESTHESIA 265 

Dr. Y. M. Griswold, of Fredonia, N. Y., first called attention 
to the hypodermic use of qiiinin as an efficient local anesthetic, 
and as being much safer than cocain, in July, 1896, before the 
Chautauqua County (New York) Medical Society.^ Dr. Gris- 
wold claims that his use of quinin as a local anesthetic is the 
result of experiments with various substances in the endeavor 
to find one equally efficient but less dangerous than cocain. 

In the Journal of the Arkansas Medical Society, for Septem- 
ber, 1907, Dr. Henry Thibault, of Scotts, Ark., in an article 
entitled, ''A New Local Anesthetic," first called attention to the 
local anesthetic effects of quinin and urea hydrochlorid. He 
recommended the use of a 1 per cent solution for local injection, 
and from 10 to 20 per cent for local application to any mucous 
surface. 

The hydrochlorid of quinin and urea, being a water-soluble 
salt, is used in the South quite extensively for the hypodermic 
treatment of malaria. It was discovered that the site of injec- 
tion of the quinin solution remained anesthetic for a considera- 
ble period of time following the injection. This fact has been 
taken advantage of, and the value of the discovery of a non-toxic 
substitute for cocain is being demonstrated by several workers 
at the present time. 

In an article in the Journal of the A. M. A., for October 23, 
1909, Hertzler, Brewster, and Rogers, of Kansas City, ]\Io., pub- 
lished a report of their work with this anesthetic during the 
preceding six months, from which I will quote somewhat : 

They started with the 1 per cent solution recommended by 
Thibault. They found, as stated by him, that a perfect anes- 
thesia is obtained, which lasts from four to six hours. The 
anesthesia is more complete than with cocain. They soon dis- 
covered, however, that disturbances in skin union sometimes 
occur. Hertzler noted particularly that in hernia operations 
there is some disturbance in healing of the skin wound which 
had not been noted after the use of cocain. The disturbance 
was not great, but the patient had to be kept in bed longer than 
after the cocain operation. The edges of the wound were in- 
durated and thickened, but there was no pus formation. The 
thickening appeared to be due to cellular infiltration. 

IBuffalo Medical Journal, August, 1896, p. 32, 



266 DisivASES 01? the: re:ctum 

Hertzler thereupon undertook to determine experimentally the 
cause of the induration. Experiments performed on rabbits 
showed that the thickening is not due to cellular infiltration 
at all, as was supposed on clinical grounds, but is due to the 
pure fibrinous exudate free from cells. This exudate was 
proved to be fibrin by Mallory and Weigert's stain. The re- 
action appears, therefore, to be purely chemical in nature. The 
exudation of the fibrin begins to appear within a few minutes. 
In a general way it was determined that the amount of exuda- 
tion depends on the strength of the solution used; the attempt 
was made, therefore, to determine a strength of solution which 
would not cause this exudation of fibrin. With ^ per cent 
solution the exudate is less than with the 1 per cent, and with 
the J4 per cent solution only traces can be discovered. To 
what extent this fibrinous exudate is subsequently converted into 
•fibrous tissue has not yet been definitely determined, but ap- 
parently nearly all is absorbed. 

In order to determine the subjective sensations of the injec- 
tion and to determine the question of a possible zone of hy- 
peresthesia about the anesthetized zone, Hertzler studied the 
efifect by injection in the skin of his own leg. Injections of 1 
per cent, ^ per cent, ^ per cent, and % per cent solutions, 
and an injection of plain water for control, were used in each 
series. The 1 per cent and ^ per cent solutions gave immediate 
and complete anesthesia without a particle of pain during its 
introduction. Within a few minutes there was a distinct indu- 
ration. With the ^ per cent solution anesthesia was not com- 
plete for a few minutes, but was then as complete as after the 
use of the stronger solution. The % per cent solution gave 
delayed anesthesia, but after a few minutes was complete. In 
neither of these weaker solutions was induration noted on pal- 
pation. The water control caused intense pain on injection, and 
the anesthesia, at no time perfect, lasted only a few minutes. 
There was a zone of hyperesthesia one or two inches in width 
about the area injected. Curiously enough, the hyperesthesia 
seemed to be for touch and not for pain. 

The duration of the anesthesia in the 1 per cent and Yz per 
cent solutions w^as perfect for four or five days, and sensation 
in the ^^ per cent strength was not restored to any great ex- 



TECH NIC 01? I^OCAI, ANESTHESIA 267 

tent for ten days, and in the 1 per cent solution sensation was 
not completely restored after two weeks. At no time was there 
the least pain, though the induration of the 1 per cent and ^ 
per cent solutions was yet marked at one and two weeks re- 
spectively. Quinin anesthesia, it will be seen, can be used for 
any operation where the use of local anesthesia is indicated. It 
has three very decided advantages over any other local anesthetic : 

1. It is non-toxic, and can be given in unlimited dosage. 
Brewster has used 100 grains intravenously within six hours 
in a patient suffering from pernicious malaria. 

2. The prolonged anesthetic eft'ect. In many cases post- 
operative anesthesia has lasted from four to five hours to as 
many days and longer. 

3. Where the solution containing 1 per cent or over is used, 
the hemostatic effect produced by the deposition of fibrinous ex- 
udate is of extreme value in preventing postoperative oozing. 

The exudate being fibrin in the strict chemical sense, the 
usual natural processes of hemostasis are anticipated. The co- 
agulum occurs, it is true, about and not in the vessels, and 
their occlusion therefore results from pressure from without. 
The important point, however, is that the effect lasts from seven 
to fourteen days, a time abundantly sufficient to allow heal- 
ing by granulation to become well advanced. This is in marked 
contrast to the ephemeral influence of cocain and adrenalin, 
which act only by causing a contraction of the muscular walls 
of the blood-vessels. 

The substitution of quinin and urea hydrochlorid for cocain, 
eucain, or any of the other anesthetic salts hitherto employed, 
will be found eminently satisfactory in all cases of rectal sur- 
gery where suturing of the integument is not required. My ex- 
perience with this drug leads me to recommend it, on account 
of its several distinct advantages over any of the other anesthetic 
drugs upon which we have previously depended. 

It is soluble in water and can be sterilized. It is equal to 
cocain in anesthetic power and is absolutely non-toxic. It has 
a pronounced hemostatic action, and postoperative anesthesia 
lasts from four hours to several days. It is inexpensive and 
almost always available. 

The use of sterile water as an anesthetic in the treatment 



268 DISEASES OF the: rectum 

of rectal and anal diseases was exploited prominently a few 
years ago, and while the author's experience with it has proved 
to him that satisfactory anesthesia in certain cases can be pro- 
duced by its use alone, he limits its use in his work at present 
to the occasional distention of internal hemorrhoids only. The 
one objection which he has found to its indiscriminate use is the 
larger degree of discomfort to the patient at the initial injection 
and the large quantities of solution required in some operations in 
the sphincterian region, causing such distortion of the tissues as 
not only to impede the work of the operator but to displace 
the parts so that accurate work could not be done. 

It is well for the reader to realize that in ''a pinch" sterile 
water can be used in lieu of any chemical anesthetic, and there 
are occasions, when he may be called upon to do work in an emer- 




Fig-. 134. Aseptic aU-glass hypodermic syringe, provided with as- 
bestos-packed plung-er. 

gency, where the various chemical anesthetics may not be avail- 
able, when with an ordinary hypodermic syringe and boiled 
water satisfactory anesthesia can be produced. 

INSTRUMENTS. 

The principal instrument required for the production of local 
anesthesia is a hypodermic syringe with a capacity of two to 
four drams, which may be constructed entirely of either metal 
or glass (Figs. 134 and 135), so that it can be readily sterilized 
by boiling. 

The needles used should be the finest that can be procured, 
and the points should always be kept sharp. A quick puncture 
zifith a sharp-pointed fine needle is almost painless, while the 
use of a larger-calibered needle with a short beveled point will 
cause considerable unnecessary discomfort to the patient. The 



TECHNIC OF LOCAI, ANESTHESIA 



269 



piston-syringe package, constructed of glass and rubber, which 
many of the manufacturers of antitoxin supply, when sterilized 
by boiling, makes a fairly good substitute for the regular aseptic 
hypodermic syringe, and in the absence of the proper apparatus 
it may be used. The objection to it is the fact that the needles 
supplied with it are usually of larger caliber and not so sharp 
as they should be for this work. The only other piece of ap- 
paratus required (and even that is not an absolute necessity) 
is a portable mechanical vibrator, armed with a cone-shaped 
rectal vibratode (Fig. 140), for use in the dilatation of the 
sphincter muscle. 

The solution used should be accurately prepared as to the 
percentage of chemical anesthetic used. Where beta-eucain lac- 
tate is employed, the solution is made up and placed in an or- 
dinary test-tube. It is sterilized by boiling over the flame of a 




Fig. 135. Aseptic all-metal syringe, 
infiltrating- through the proctoscope. 



provided with extension for 



Bunsen burner or spirit lamp, and then stoppered with absorb- 
ent cotton and allowed to cool. The solution is prepared fresh- 
ly for each operation. The quinin-urea solution is prepared in 
like manner when the tablets are used. 



GENERAL TECHNIC. 

The patient is prepared for the operation as follows : 
Twenty- four hours before the operation, he is given a brisk 
cathartic and is instructed to partake of nothing but liquid food 
thereafter. On the morning of the operation the bowels are 
washed out by means of a large soap enema, and he is directed 
to report at the office about one-half hour before the time for 
operation. He is then given a quarter of a grain of morphin or 
one sixth of a grain of pantopon by mouth. 

When ready to operate, the patient is placed upon the table 
in the left lateral position, the left leg extended and the right 



270 



diskase:s 01? the: re:ctum 



well flexed. The clothing is placed well out of the way, and the 
patient covered with clean sheets. The anus and perineum are 
shaved and scrubbed with liquid antiseptic soap, then washed 
with a 1 :1000 solution of iodid of mercury, which is washed off 
with sterile water, and a compress of alcohol applied. A point 
one-half inch below and posterior to the posterior commissure 
of the anus is selected (Fig. 136). A swab moistened with pure 
carbolic acid is applied to lessen the pain which accompanies 




Fig. 136. Exact point of puncture for the injection of local anes- 
thetics for dilating the external sphincter. With the patient in the 
lateral position, a point from i/4 to % inch posterior to the posterior 
commissure of the anus is chosen for the first injection. 



the introduction of the needle. Wherever it is possible, the in- 
dex finger of one hand, protected by a finger cot and well lu- 
bricated, is inserted in the anus, and the sphincter is pulled 
downward and backward. The syringe, containing about one 
dram oi ]/% io % per cent solution of eucain lactate, with a 
fine sharp-pointed needle about two inches in length attached, is 
held in the other hand. The needle is inserted quickly, just 
underneath the skin, and 4 to 5 drops of the solution slowly in- 



TECPINIC OI^ I.OCAI, ANESTHESIA 



271 



jected. One should he extremely careful about injecting the so- 
lution too quickly, as this part of the procedure is the most pain- 
ful and often needlessly causes suffering, particularly to the 
timid and neurotic patient. The point of the needle is then 
passed inward and laterally, going down toward and into the 
external sphincter muscle, which, guided by the finger in the 
rectum, is brought down toward the needle. The point of the 




Fig-. 137. Quadrants of the anus. 

1. Right antero-lateral quadrant. 

2. Left antero-lateral quadrant. 

3. Right postero-lateral quadrant. 

4. Left postero-lateral quadrant. 



needle should be kept about one-half inch from the anal aperture, 
and the injection is carried up along the right postero-lateral 
quadrant (Fig. 137) of the anus for about three- fourths to an 
inch. The needle is then retracted to the point of puncture but not 
withdraimi. It is then pushed up on the left side in the same 



272 



dise:ases of the: rectum 



manner, injecting the opposite side so that when the injection 
is completed the wheal of infiltration is U-shaped, the apex 
being at the point of puncture (Fig. 138). 

This technic allows of the anesthetization of the sphincterian 
nerves of both sides from but a single puncture. Care should 
be taken lest the rectal wall be punctured, but with the index 
finger of one hand in the anus during this procedure, such an 




Fig". 138. Showing- the amount of distention necessary in anesthe- 
tizing the sphincters. 

accident should not occur. The anesthetization of the anterior 
sphincterian nerves is accomplished in a similar manner, but is 
only required where a pathological condition on the anterior 
anal wall is to be operated (Fig. 139). 

Three or four minutes are allowed to elapse to allow com- 
plete anesthesia to take effect; then the vibrator, to which has 
been attached the cone-shaped vibratode, well lubricated, is 
pressed against the anus (Fig. 140). With very little pressure, 



TPXHNIC OF I.OCAL ANESTHESIA 



273 



but with the apex of the vibratode kept in the direction of the 
axis of the anorectal canal, from two to three minutes' vibra- 
tion will dilate the sphincter painlessly to a sufficient caliber 
to allow whatever operation is to be done to be accomplished 
without difficulty (Fig. 141). Complete divulsion of the sphinc- 
ter can very rarely be accomplished by this means, and is not 
ever necessary, but the dilatation will be amply sufficient for our 
purposes. 




Fig-. 139. Exact point of puncture for anesthetizing- anterior 
sphincterian nerves for dilatation of the ex'ternal sphincter. 



The vibrator is a very convenient apparatus to have at hand, 
as the dilatation can be more quickly and evenly accomplished by 
its use. In its absence, however, one may use the index fingers 
of both hands, protected by finger cots or rubber gloves, and by 
a gentle to-and-fro massaging movement, gradually accomplish 
dilatation in a very satisfactory manner. One should never use 
any of the dilating rectal speculums in the dilatation of the 
sphincter. The fingers are far better dilators, and can do no 
damage with intelligence and care behind them to guide. 



274 



dise:ase:s o^ the: re:ctum 



TECHNIC IN SPECIAL CASES. 

The technic for operating for the various conditions amenable 
to operative treatment under local anesthesia will be dwelt upon 
more in detail in their respective chapters, while the differences 
in technic of anesthetization will be taken up below. Suffice it to 
say, however, at this point, that no operation upon the anus 
or rectum should he undertaken under local anesthesia, zuhich 




Fig. 140. Posture and method of producing' dilatation of the sphinc- 
ter ani by the use of a portable vibrator, armed with a cone-shaped 
vibratode. 



zvill require extensive dissection or over twenty minutes of time 
for its completion. 

External Kemorrhoids. — If the hemorrhoid is entirely ex- 
ternal and is not complicated by any other anal condition, it 
will not be necessary to anesthetize the sphincter. After the 
usual preparation for the operation, the most dependent hem- 
orrhoid is injected from its base with }i per cent solution of 



TOCHNIC OF I.OCAI, ANESTHi:SlA 



275 



eucain lactate, about 20 to 30 minims being used directly under 
the skin. If further distention is recjuired in order to pro- 
duce complete anesthesia, 1 per cent cjuinin-urea solution may be 
used for the deeper injection. After ten minutes the skin 
may . be incised painlessly, and the operation proceeded with. 
Where more than one hemorrhoid is to be operated, they may 
all be anesthetized at once, if the operator is rapid in his work; 




Fig'. 141. Amount of dilatation of the sphincter under local anes- 
thesia. This drawing-, made from a photog-raph of one of the author's 
cases of internal hemorrhoids, well illustrates the amount of dilatation 
of the sphincter that may be produced by local anesthesia. While 
complete divulsion is rarely possible or necessary, sufficient distention 
is here secured to remove successfully the internal hemorrhoids shown 
in the drawing-. 



otherwise they had best be anesthetized separately when ready 
to operate on each. 

Acute Thrombotic Hemorrhoids. — The acute thrombotic 
hemorrhoid is usually single, occurring just at the anal mar- 
gin. After being prepared for operation, eight or ten drops of 
the 1 per cent quinin and urea solution is injected just beneath 
its outer covering, whether skin or mucous membrane, care be- 



276 dise:ases o^ the: rectum 

ing taken not to inject deeply and into the clot. Sufficient so- 
lution should be used to distend the tissues over the clot and 
blanch them to whiteness. It may then be incised painlessly, 
and the clot turned out. It is well after the turning-out of the 
clot to inject the tissues beneath it, and examine carefully, as 
usually more clots will be found beneath the first, which must 
be removed in like manner. 

Perianal Abscess. — In those cases of perianal abscess not 
extensive enough to require general anesthesia for their opera- 
tive treatment, the use of a local anesthetic is well adapted. The 
technic of injection is the same as that outlined above for throm- 
botic hemorrhoids. The reader is cautioned to make his in- 
jection very carefully, so as not to perforate the abscess cavity 
with the needle. The solution must be injected into the skin 
itself and directly under it. After waiting at least five minutes 
for anesthesia to take place, the abscess may be opened with 
absolutely no pain. 

Anal Fissure. — In all cases of fissure, the sphincter should 
be anesthetized and dilated. In many cases where the fissure 
is situated low down, the anesthetic solution injected for the 
anesthetization of the sphincter will also be sufficient for the in- 
cision or excision of the fissure as well. Where the fissure is 
more extensive and with an indurated base, or is located at 
some other portion of the anus than its usual site, the posterior 
commissure, it must be injected separately. A solution of eu- 
cain YiQ per cent, or 1 per cent solution of quinin and urea hy- 
drochlorid, may be used. The syringe should be filled. The 
needle should be inserted about one quarter of an inch below the 
outermost extremity of the fissure, or beyond the sentinel pile 
when one is also present. 

The skin and mucous membrane surrounding the fissure or 
induration, as the case may be, should be infiltrated to such an 
extent that the fissure is raised on a white waxy-looking mound 
and lies, as it were, on a \yater-bed. It may require as much as 
three drams of solution, but distention of the tissues is essen- 
tial before thorough work can be done. Anesthesia should be 
carried below the base of the fissure for at least a quarter of 
an inch. 

Fistula. — The only variety of fistula in which it is advisable 



TlvCHNIC 01^ LOCAIv ANESTHESIA 277 

to use local anesthesia as a routine measure is that of a simple, 
shallow, complete fistula whose course is direct and not branch- 
ing. A blind external or internal fistula whose opening is not 
over one inch from the anus, and whose extent can be accurate- 
ly gauged, may be opened under local anesthesia. As a general 
proposition, with the exception of the three varieties mentioned, 
general anesthesia (nitrous oxid and oxygen whenever possible) 
should be used in operations for anal fistula. The sphincter should 
be anesthetized in all cases. The skin and mucous membrane 
above the fistula should be infiltrated with the 1 per cent quinin- 
urea solution, and then by successive injections the entire fistu- 
lous tract surrounding with the injected anesthetic fluid. The 
infiltration should be carried to the point of blanching. The op- 
eration then may be proceeded with as outlined in the chapter 
on fistula. 

Hypertrophied Anal Papillae. — In cases where hypertrophy 
of the anal papillae is not accompanied by a tightly contracted 
sphincter, it is possible to remove the papilla under local anes- 
thesia without dilatation of the sphincter. It is advisable, how- 
ever, in order to overcome the tenesmus and painful spasmodic 
contractions of the sphincter following any operation in the 
anal canal, to anesthetize the sphincter as a general rule in re- 
moving these papilla. Wliere this is done the anus is held open 
by means of a retractor, and each papilla is injected from base 
to apex with the 1 per cent quinin-urea solution. It may then be 
removed painlessly, and each successive one injected in turn be- 
fore removal. 

Where the sphincter is not anesthetized, the use of a short 
anoscope with an oblique opening, such as has been described by 
the author, will be required. The papilla, as it hangs down 
or projects into the opening of the anoscope, is injected by means 
of a long needle attached to the hypodermic syringe, and in- 
jected as described above. Where it is desired to open the 
crypts of ]\Iorgagni as well, the needle should be carried up for 
half an inch or so, when, after the removal of the papilla, the 
crypt can be split open at will. 

Hypertrophied Rectal Valves. — In operating for the section 
of hypertrophied Houston's valves, the dilatation of the sphincter, 
as outlined above, is often the only part of the operation, where 



278 dise:ase:s o^ the rectum 

a local anesthetic is required. The valves themselves are very 
poorly supplied with sensory nerves, and as a result, incision is 
painless. In some cases, however, there is some sensitiveness to 
pain; so it is wise in all cases tO' be on the safe side, and apply 
by means of an applicator bent at a right angle a 2 per cent solu- 
tion of beta-eucain to both upper and lower surfaces of the 
valve. After waiting two minutes, operation may be begun. 

Removal of Foreign Bodies. — Oftentimes small splinters of 
bone, pins, or other swallowed foreign bodies will traverse the 
entire gastrointestinal tract without doing any injury or be- 
coming lodged, until they reach the loAver end of the rectum, 
when they impinge against the rectal aspect of the mucous mem- 
brane covering the sphincter muscle, or lodge in one of the crypts. 
By their constant irritation, they cause spasm of the muscle and 
intense suffering. On account of the tonic contraction of the 
sphincter, which is caused by this irritation, any attempt at the 
insertion of a proctoscope or even the finger is usually futile. 
The dilatation of the sphincter by means of the technic outlined 
above is nowhere more applicable than in this class of cases, 
and not only such foreign bodies as have been mentioned, but 
fecal concretions and impactions of considerable size as well, 
can be removed without the employment of a general anesthetic. 

Removal of Benign Perianal Growths. — Small benign 
growths situated at or near the anal orifice, such as dermoids, 
sebaceous cysts, lipomata, or condylomata, are very satisfactorily 
removed under local anesthesia, with the following technic: 

After the parts are cleansed, shaved, and sterilized, condylo- 
mata are removed by the application of a 2 per cent solution of 
eucain to the parts, which is repeated every two or three minutes 
for ten minutes. Then, if anesthesia is not complete, the parts 
are sprayed with ethyl chlorid solution, the condylomata quickly 
snipped off close with sharp scissors curved on the flat, and fum- 
ing nitric acid applied with a wooden applicator, or a small tight 
swab. Boro-chloretone powder is then applied, and the parts 
covered with a gauze dressing. In the case of a dermoid, 
sebaceous cyst, or fatty tumor, the technic is the same for the 
removal of any of the three varieties. The skin covering the 
tumor is first injected with Ys per cent solution of eucain lactate, 
a wheal or welt being formed over the proposed line of incision. 



TKCHNIC OF LOCAI. ANESTHESIA 279 

The incision is made, and the tissues above and surrounding the 
tumor infiltrated with 1 per cent solution of quinin and urea 
hydrochlorid, when the dissection and removal of the growth can 
be accomplished easily, with forceps and scissors. Care should 
be taken in the case of a cystic tumor not to puncture the cyst 
wall with the injecting needle, and in the excision of the growth 
to be sure to remove all of the sac. If this is not done, recur- 
rence is likely. 

Posterior Internal Proctotomy for Annular Stricture Situ- 
ated in the Anal Canal or Not Over an Inch Above the Ano- 
rectal Juncture. — A\"ith the patient in the left lateral position, 
and prepared for operation, the region posterior to the anus. 




Fig-. 142, ■\'\'ales rectal bougie. This is made of flexible rubber 
and provided with a canal, through which the irrigation may be given, 
and which allows the entrance of atmospheric air and escape of gas 
during its introduction. There are twelve different sizes. 

anal canal, and stricture is infiltrated with 1 per cent solution 
of quinin and urea hydrochlorid. After waiting ten minutes 
for anesthesia to take full effect, the stricture is divided in the 
posterior median line down to the rectal wall with a sharp 
scalpel, a piece of gauze inserted, and the operation is complete. 
The author's technic for rectal valvotomy by the use of the 
rubber ligature may be substituted for the incision, if the cahber 
of the stricture is sufficiently large to admit the ligature 
carrier. After operation, the recurrence of the stricture is pre- 
vented by the introduction of Wales' bougies (Fig. 142) up to 
size No. 12, twice a week at first, and at increasing intervals 
until complete healing has taken place. 



280 disi:ase:s 01^ the rectum 

After carefully perusing what has been said regarding the 
employment of local anesthesia, and bearing in mind the contra- 
indications and objections, as outlined in the following chapter 
on Limitations of Local Anesthesia, other diseased conditions of 
not only the rectum and anus, but in other parts of the body, will 
present themselves, in which the employment of local anesthesia 
will be found very advantageous ; and the results obtained there- 
from fully as successful as where, heretofore, the employment of 
general anesthesia has been thought absolutely necessary and in- 
dispensable. 



CHAPTER XVI. 

LIMITATIONS OF LOCAL ANESTHESIA AND OF- 
FICE TREATMENT AND INDICATIONS 
FOR OTHER MEASURES. 

While the primary object of this work has been to bring be- 
fore the profession the advantages to be gained from the treat- 
ment of various rectal diseases in office practice, and to 
demonstrate the advantages of the use of local anesthesia in the 
treatment of many of the more common conditions met in 
connection with the treatment of diseases of the anus and rec- 
tum, it has been thought wise to utter a warning note, lest the 
reader be led away by overenthusiasm. 

While the author believes that the field for the employment 
of local anesthesia in rectal surgery, as well as in other branches 
of practice, is rapidly widening, he wishes to impress upon the 
reader that this Held has definite limitations a)id that there is, 
and ahvays will be, a large class of cases n'liose successful treat- 
ment requires more radical measures, -whicJi only can be em- 
ployed by the aid of full general surgical anesthesia. 

If the reader has carefulh' read what has been written upon 
means and methods of diagnosis, and has noted in the various 
chapters following the class of cases in which the author advo- 
cates the use of non-surgical measures and the employment of 
local anesthesia, he will have noted that the methods of treat- 
ment advocated are confined to a very definite class of cases. 
All of the conditions treated of have been located either at, or 
in the immediate vicinity of, the anal canal, or were those af- 
fections of the miucous membrane of the rectum or lower sig- 
moid which are accessible to treatment through the proctoscope 
or sigmoidoscope. 

The first thing one should remember, before commencing the 
treatment of any pathological condition found in the region of 
the anus, is that, until a careful exploration of the entire .rectal 
cavity has been made, and every portion of it examined with the 
eye, he has not made a diagnosis, and has no right to treat the 

281 



282 dise:asp:s of the: rectum 

patient until he has. It would be a sad and unfortunate dis- 
covery for the physician who has been treating an anal ulcer, 
or pruritus, or hemorrhoids to find, after several weeks, 
that the condition under treatment was merely secondary to an 
extensive ulceration higher up in the rectum, a stricture, or 
malignant disease (Frontispiece). 

GENERAL CONTRAINDICATIONS TO LOCAL 
ANESTHESIA. 

In women, suffering from pelvic troubles which may require 
laparotomy for their relief, the removal of any minor rectal 
condition present under local anesthesia had better be postponed, 
and the rectal or anal condition treated at the time of laparot- 
omy. 

In patients suffering from irregularity or interruption of their 
normal bowel movements, it is wiser to exclude by careful ab- 
dominal examination, and the use of radiographs taken in both 
the upright and prone positions, any possibility of chronic in- 
testinal obstruction due to some abdominal growth, ptosis, dis- 
placement, or adhesions, than to attempt to relieve the patient 
by means of rectal dilatation and massage. 

Every patient presenting himself with a fissure or ulcerative 
condition of the anal canal should be carefully questioned as to 
the possible history of previous syphilitic infection. The presence 
of gonorrheal discharge is a contraindication to operative meas- 
ures until the discharge is remedied. In women, a purulent vag- 
inal discharge as well as the menstrual flow is, of course, a con- 
traindication. 

Patients suffering from profound anemia are always bad sub- 
jects for operation at one's office under local anesthesia, and a 
history of hemophilia should always be excluded before office 
operations. Patients of a highly neurotic temperament and 
hysterical females are best operated at home or in the hospital, 
and under general anesthesia. In other words, the suitable cases 
for oifice treatment are those suffering from diseased conditions, 
zifhose pathological source is located on either the mucous sur- 
face of the rectum and lower sigmoid, and are definitely circum- 
scribed in area and not of a malignant, syphilitic, or tubercular 
type; or lesions occurring at or around the anal orifice, whose 



iviMiTATioNS 01? oi^^ice: tre;atme:nt 283 

outlines can be definitely marked out by the diagnostic means 
outlined in the fore part of the book. 

CANCER OF THE RECTUM. 

One of the greatest satisfactions to the practitioner, who as 
a routine measure makes a proper rectal examination of his pa- 
tients whose symptoms would seem to indicate it, is the dis- 
covery of commencing malignant disease early enough to allow 
of the removal of the primary focus, and to save the pa- 
tient's life. As has been said before, a history of rectal hemor- 
rhage, however slight, is an imperative demand for complete ex- 
ploration of the rectal cavity, and the most important condition 
for which to be on the lookout, which makes itself manifest 
early by rectal hemorrhage, is cancer. It is in this condition, 
above all others, where an early complete proctologic and sig- 
moidoscopic examination will achieve brilliant results, if the 
findings therefrom will result in an early operation for the re- 
moval of the growth. It is the same with malignant diseases in 
this part of the body as in all others — if the surgeon can only get 
at them early enough to thoroughly eradicate, he can relieve them 
with a pretty definite hope of permanent cure. 

Inasmuch as rectal cancer most frequently occurs in the lower 
part of the organ, the early operation and complete removal are 
productive of much good. Some of the early symptoms of com- 
mencing cancer of the rectum or sigmoid are flatulence with 
colicky pains, diarrhea, alternating zuith constipation, tenesmus, 
increased mucous discharge, which is usually offensive in odor, 
and hemorrhage. This hemorrhage is very slight at first, often 
showing a few blood streaks with the mucus, or small passages 
of blood either with the stool or occasionally between bowel 
movements. The nearer to the anus the cancer is located, the 
earlier in the disease the hemorrhage, on account of the trau- 
matism to the growth caused by the passage of the feces. 
Cachexia, loss of weight, and impairment of general health are 
not early signs of rectal cancer. The indican reaction is usually 
present in urine in cancer, while it is absent in ordinary diarrhea. 

Diarrhea which persists for some time, which is accompanied 
by the presence of blood, however slight, should be regarded as 
suspicious, and the patient carefully watched. When one con- 



284 



dise:ase;s oi? the rectum 




Fig-. 143. Proctoscopic view of cai^cinoma, situated just below the 
juncture of rectum and sig-moid. 




Fig-. 144. Carcinoma shown in the preceding illustration, drawn 
from the specimen removed by operation. 



IJMITATIONS OF office: TRKATME:nT 



285 



siders that jO per cent of all cancers occur in the gastrointestinal 
tract, and that i6 per cent of all cancers of the digestive tract 
occur primarily in either the rectum or sigmoid flexure, one 




Fig. 145. Cancer of the rectum, with multiple fistulse. This draw- 
ing, made from a photograph of a case referred to the author, tells a 
pathetic story. The patient, a woman aged 52, suffering from various 
digestive disturbances and the appearance of blood with the stool, 
made her own diagnosis of "bleeding piles"; after six months of self- 
treatment, she consulted an irregular advertising quack, who confirmed 
her diagnosis of "hemorrhoids," and proceeded to "absorb the growth 
by electricity." When her money ran out she was sent home cured. 
Her condition one month later, when seen by the author, is illustrated 
above. The area of infiltration involved the entire anus, posterior wall 
of the vagina, and all of the perineal wall between. Her perineum was 
riddled with abscesses and fistulse. The rectum and vagina communi- 
cated througli a large rectovaginal fistula, and the posterior wall of 
the bladder was infiltrated. The case was hopeless, and she died 
shortly afterward. 



commences to realize the importance of examining every case 
which presents a history of rectal hemorrhage, however slight, 
no matter the age or general appearance of the patient. 



286 disj:ase:s o^ the: re:ctum 

Well-authenticated cases of cancer of the rectum have been 
found in cases as young as fifteen years of age. To show how 
much more frequently cancer is prone to locate in this part of 







Fig-. 146. Cancer of the rectum. This specimen, which includes 
the entire rectum and lower portion of the sigmoid, being twelve 
inches in length, was removed by the author by the perineal method, 
the sphincters being preserved. This case will illustrate the value of 
early diagnosis and prompt operative interference in cancer of the 
rectum. The patient, aged 50, suffered from gradually increasing dis- 
turbances of the digestive functions for about six months. The symp- 
toms gradually grew worse, and she noticed that her stools were be- 
coming smaller in caliber, and accompanied by a small quantity of 
blood. She consulted her physician, thinking that she had hemor- 
rhoids. He immediately made a proctoscopic examination, and dis- 
covered just below and extending to the rectosigmoidal juncture a 
crater-like ulceration with raised edges projecting into the lumen of 
the bowel. A diagnosis of rectal cancer was made, and the case re- 
ferred to the author for operation. There was no extrarectal involve- 
ment, and the complete extirpation of the diseased rectum and lower 
sigmoid was followed by a rapid recovery of the patient. Four years 
after the operation she reported herself in perfect health, with no 
signs of recurrence. 



LIMITATIONS 01^ oi^i^ice: tri:atme:nt 



287 



the body than is generally supposed, it may be stated that Boas 
found in 500 cases of cancer of the digestive tract, 83 cases of 
cancer of the rectum. In the personal practice of the author, 
very frequently patients are brought in by practitioners, many of 
whom really try to do conscientious work, with unsuspected 




Fig-. 147. Cancer of the rectum. Same as the preceding. Interior 
view of the specimen. (The lettering- on the preceding specimen cor- 
responds to that below.) 

A. Point of amputation from the anus. 

R. Rectum. 

X. Cancer. 

S. Sigmoid flexure. 



cancer of the rectum. Many of these patients are in the forties, 
present robust appearance, and come with a history of some 
bleeding from the rectum from which they make their own 
diagnosis of ''bleeding piles." They also complain of some dis- 
turbance of bowel movements, either constipation or diarrhea, and 



288 dise:ases of the rectum 

disturbed gastric and intestinal digestion, and occasionally a not 
very well-defined aching in the sacral region. 

In many of these cases proctoscopic (Figs. 143, 144) and sig- 
moidoscopic examinations have demonstrated the presence of can- 
cer of the rectum, so far advanced as to cause almost complete 
occlusion of the lumen of the bowel, and too far advanced to 
extirpate with any hope of cure. It is the unfortunate experience 
of many proctologists to be called upon to inform many of these 
patients of their hopelessness, and it is with the hope of bring- 
ing the profession in general to realize the importance of ex- 
amination of the rectal cavity in all cases presenting the symp- 
toms just mentioned above, that so much stress is being laid on 
the importance of early examination of the rectum by the general 
practitioner (Figs. 145-147 and Frontispiece). 

ULCERATION OF THE BOWEL. 

Cases of ulceration of the bowel involving more than one cir- 
cumscribed area which have become chronic, as well as the very 
extensive ulcerations due to the specific infections like tubercu- 
losis and syphilis, are not suitable cases for office or local treat- 
ment. It has been found in the experience of most proctologists 
that the only satisfactory way by which such cases may be cured 
is by "sidetracking" the fecal current by means of a temporary 
colostomy. This removes the mechanical as well as the bacterial 
irritation from the ulcerated surfaces and puts the parts at rest ; 
after which irrigations and other suitable therapeutic measures 
can be applied from above, as well as below. These cases, how- 
ever, require more or less confinement in bed or in the house, 
and are best treated only in the surroundings which the modern 
hospital can best supply. 

While it is true that colostomy can be performed under local 
anesthesia, as the author has demonstrated in several cases, it 
is hardly to be advised to be performed by the general practi- 
tioner or included in the same class as the operative measures or 
diseases mentioned in the foregoing chapters. 

STRICTURE OF THE RECTUM. 

No case of stricture of the rectum should be treated, whether 
by dilatation, incision, or electricity in office practice, unless it 



I^IMITATIONS 0^ O^I^ICE TREATMENT 289 

is situated within the first two inches of the anorectal canal, and 
is not smaller in caliber than the circumference of a No. 10 
Wales bougie. Even then, its situation, consistency, structure, 
and relation to the rectal walls and impinging organs should be 
definitely ascertained by radiographic, digital, and instrumental, 
as well as ocular, examinations. Great caution must be observed 
in using forcible dilatation in any case of stricture of the rectum, 
no matter how elastic the stricture may seem. Accidents have been 
reported where the rectum has been torn through, and the peri- 
toneal cavity entered with fatal result, from the simple dilata- 
tion of large-calibered strictures by means of the Wales bougie. 
Cases of "stricture,'' due to unusual infiltration of one of Hous- 
ton's valves, or strictures of the umbrella type, can be easily 
divided by i-yeans of the author's rubber-ligature operation, as 
applied to hypertrophied rectal valves. 

Where the administration of nitrous oxid with oxygen is so 
easy, and attended with practically no danger, its use is to be ad- 
vocated in those cases where operation of a short duration is all 
that is required, for which general anesthesia is absolutely neces- 
sary. 

RECTAL ABSCESSES. 

While, as has been pointed out in a preceding chapter, some 
circumanal and perirectal abscesses are amenable to treatment, 
within certain limitations, under local anesthesia, abscess forma- 
tion may go on to such a point, where it is absolutely necessary 
to do a more extensive operation than is possible under local 
anesthesia. Certainly no abscess which extends above the levator 
ani muscle should ever be opened under local anesthesia; nor 
any abscess in the ischiorectal region, in which there is any doubt 
as to the operator's ability to obtain a large and free drainage 
opening by means of incision without curetting. Owing to the 
ease with which it enlarges in the ischiorectal region, it is a safe 
plan not to attempt to open any abscess under local anesthesia, if 
it has become larger than a hen's egg in size, unless a definite 
point of fluctuation and softening can be detected at a point 
well outside the sphincters. 



290 disi:asks 0^ the: rectum 

ANAL FISTULA. 

No case of anal fistula which has more than one channel, or 
whose limits can not be definitely made out by digital examina- 
tion, should be opened under local anesthesia. In fact, the only 
safe way is to obtain a stereoscopic radiograph after the injec- 
tion of bismuth paste. Only the sim.ple, direct, complete, or blind 
external, blind internal, or submucous fistulse, are amenable to 
operation under local anesthesia, and in case of doubt, nitrous 
oxid or ether should be employed. One never can tell how 
high, or how extensive, a_ dissection may be required for the 
complete removal of a fistulous tract, or which is the ideal opera- 
tion, unless he is guided by a good set of radiographs. 

HEMORRHOIDS. 

In operating for hemorrhoids under local anesthesia, one must 
be extremely careful in the selection of cases. Hemorrhoids, 
complicated with fistula, extensive ulceration, complete rectal 
prolapse, or abscess, are best treated only under general anes- 
thesia. External hemorrhoids and acute thrombotic hemorrhoids 
can almost invariably be removed under local anesthesia, fully 
as satisfactorily as by the use of a general anesthetic. In the 
treatment of internal hemorrhoids and externo-internal hemor- 
rhoids, however, there is a limit beyond which it is possible to 
go, but not wise. 

The author in his practice has laid down the following rules: 
In all cases of internal hemorrhoids where not more than five 
or six separate hemorrhoidal tumors are present, whether pro- 
lapsing or not (Fig. 100), operation under local anesthesia is 
the method of choice. Where more than six distinct hemor- 
rhoidal tumors are present, or where there is a great deal of 
rectal prolapse complicating, their removal under nitrous oxid 
and oxygen anesthesia is advised. Where, however, it is deemed 
unsafe or inexpedient, or where the patient absolutely refuses 
to take a general anesthetic, the more severe cases can be oper- 
ated on under local anesthesia by operating at several different 
sittings, removing two or three hemorrhoids at a time, and then 
in a month or so removing more, eventually accomplishing the 
complete removal of all the hemorrhoids in three or four months 



I^IMITATIONS OF office: TRE:aTME:nT 291 

and by as many operations. In some patients suffering from 
cardiac, pulmonary, or renal disease, such a method may have to 
be followed where the administration of a general anesthetic 
would be absolutely prohibited. 

In cases suffering from interno-external hemorrhoids, where 
there are more than five or six separate tumors, their removal 
may be accomplished in two sittings, by removing the external 
portions at one operation, when, with these out of the wa}^ the 
internal ones can be removed with ease at the next sitting. 

PROLAPSE OF THE RECTUM. 

In prolapse of the rectum of the second degree, where the pro- 
lapse only involves one half of the circumference of the bowel, 
local anesthesia may be employed, and the prolapsed portion 
ligated off in sections. As a general proposition, however, the 
author does not advise its use. Operations for prolapse have 
been done by some proctologists under local anesthesia; but the 
technic is rather crude, and the same satisfactory results can- 
not be obtained in this hurried method, as are possible under 
general anesthesia. In prolapse of the third degree (Fig. 132), 
local anesthesia is obviously contraindicated, as the most suc- 
cessful operation for the reduction of complete prolapse is best 
accomplished by means of an abdominal operation. 

REMOVAL OF CONCRETIONS. 

The removal of concretions from the rectum or sigmoid, which 
are larger than one inch and a half in circumference, should not 
be attempted under local anesthesia, but can be done very nicely 
under the anesthesia produced by the administration of nitrous 
oxid and oxygen. While almost any case of fecal impaction can 
be relieved under local anesthesia, as has been pointed out in 
Chapter V, there are some cases in which the procedure fatigues 
the patient so much that the administration of a general anes- 
thetic may be necessary in order to successfully complete the 
operation. 



292 dise:ase:s o^ the: rectum 



FISTULA COMMUNICATING WITH OTHER ORGANS. 

Operations for fistulse communicating between the rectum and 
other adjacent organs should never be attempted under local 
anesthesia, neither should the extensive use of the thermocautery 
be attempted unless the patient is under profound anesthesia, 
if used at all. Before attempting any operation for relief of any 
pathological condition discovered in the anus or rectum, the ab- 
sence of any other diseased condition higher up in the rectum 
should first be demonstrated by careful proctoscopic and sig- 
moidoscopic examinations. 



CHAPTER XVII. 

THE FECES AXD THEIR CLINICAL EXAMIXATIOX. 

By George W. Wagxer. M. D.. Detroit. :vlich. 

It is surprising that in the study of intestinal diseases so Httle 
attention has been given to the careful study of the stool. The 
study of the feces bears the same relation to the study of in- 
testinal derangements as the examination of the urine to the diag- 
nosis of renal diseases. 

The author has. as far as possible, included only the practical 
part of coprology, omitting those procedtires that are of no par- 
ticular benefit to clinical medicine and those requiring special 
laboratory training. 

Lender the term feces are comprised all those substances which, 
being formed from the food in the process of digestion, and 
mixed with the residue of the secretions of the alimentary canal, 
are finally expelled by the rectum. 

GENERAL CHARACTERISTICS OF FECES. 

Number of Stools. — The number of stools in 24 hours varies 
greatly in different persons, who are apparently in good health. 
One may have two or three bowel movements in 24 hours, while 
another may have one in 48 hours : so it is important to ascertain 
the habitual number of stools, in every individual. There are 
rare instances in which one stool occurs only in two weeks to 
four months. It is better, however, to take the general condition 
of the patient as a guide to the sufficiency of defecation. Some 
individuals will tolerate infrequent defecations, while others would 
sufter from copremia imder the same conditions. 

Duration of Passage. — The question of the length of time 
required for the passage of food through the gastrointestinal 
canal is a matter of much clinical importance ; yet little attention 
has been paid to the subject. It is quite as important to know 
the period of passage as to know how often the patient has a 
stool. A patient may have one stool a day and yet have latent 

293 



294 DISEASl^S 01^ THE RECTUM 

constipation, which gives rise to toxic symptoms. Wiether latent 
constipation is present can only be determined by estimating the 
period of passage. In diarrhea, by estimating the period of pas- 
sage, it is possible to come to an approximate idea of the seat 
of the disturbance producing the diarrhea. If the period of pas- 
sage is nearly normal, the trouble lies in the lower or middle por- 
tion of the large intestine, and peristalsis is probably not in- 
creased in the small intestine. Chronic colitis, with several 
watery movements a day, may be accompanied by a normal pas- 
sage. The period is decidedly shortened if the inflammation is 
in the ascending colon or small bowel. Strauss used a test-diet 
of 100 grams of lean meat and found the normal period to be 
10 to 20 hours. This was increased in cases of constipation to as 
high as 60 hours. Maurel, using a pure milk diet, gives the 
normal period 36 to 48 hours. In disease the shortest period was 
4 hours, and in such cases the bilirubin is found unaltered. The 
period of passage is very easily marked by giving a capsule of 
carmine with the meal and watching for the first red stool. 

Amount. — The amount varies in different individuals, de- 
pending upon the character of the diet and the condition of the 
digestive organs. The quantity is increased by a diet rich in 
vegetables and starchy foods, and diminished by one rich in 
animal food. 

The stool consists of the indigestible portion of the diet, the 
part of the diet undigested, bacteria, and the secretions of the in- 
testines and their associate glands. Cetti, who fasted 10 days, 
passed about 22 grams of stool on the average a day. The 
normal amount varies between 100 and 200 grams in 24 hours. 

Consistency and Form. — The consistency of the stool de- 
pends chiefly upon the amount of water it contains, though there 
may be soft, thin stools due to abnormal amounts of fat or mucus. 
Increase of the fluid in the stools may be due to deficient absorp- 
tion, or to exudate or transudate from the mucous membrane. 
Increased peristalsis may cause watery stools through failure of 
absorption, while prolonged retention in the colon or rectum may 
result in hard, scybalous masses due to excessive absorption of 
water. 

Odor. — The odor of the feces is, to a large extent, due to 
the presence of indol, skatol, sulphuretted hydrogen, and methane. 



EXAMINATION O^ FECES 295 

Color of Stools. — The color of the feces varies according to 
the nature of the food ingested. The normal color is dark brown. 
A diet consisting largely of meat gives an intensely brown stool, 
while a vegetable diet gives a more yellowish shade to the feces. 
A stool that has been exposed to the air is darker on the outside 
than on the interior, owing to the process of oxidation. The 
presence of undigested fats gives a yellowish shade to the stool. 
If much blood is present the stool may be black or have a tarry 
appearance. Huckleberries and red wine produce a dark stool ; 
chocolate and cocoa, gray ; iron, manganese, and bismuth prepara- 
tions, a dark or black stool, owing to the formation of the oxids 
of these metals (Fig. 148). Calomel causes a greenish stool 







Fig-. 148. Sulphid of bismuth crystals from the stools. (Eyepiece 
III, objective 8A, Reichert.) — Von Jaksch and Cagney: Clinical Diagnosis. 

(biliverdin) ; santonin, rhubarb, and senna produce a yellow 
color. 

Macroscopic Elements. — These are derived either from the 
food or from the intestinal apparatus itself. It is possible to 
find stones, cherry pits, grape seeds, skins of various berries or 
apples, pears, etc., pieces of connective tissue, grains of corn — 
in fact, almost any part of the food if insufficiently masticated. 
The presence of casein in the stools of infants appears as small 
whitish lumps and can, as a rule, be easily recognized. Foreign 
bodies of almost every description, which are not too large to 
vSwallow, may be found in the stools, especially in the stools of 



296 



DISe:aSE:S 01^ THE RECTUM 



children and of the hysterical or of the insane; one may find 
buttons, coins, pins, false teeth, hair balls, etc. 

Microscopic Elements. — Microscopically, may be seen in- 
digestible and undigested portions of the food, as well as sub- 
stances thrown off by the mucous membrane of the intestines. 
Thus, starch granules and remnants of chorophyll, muscle-fibers, 
elastic-tissue fibers, connective-tissue fibers, flakes of casein, white 
blood-corpuscles, triple phosphate crystals, micro-organisms, etc., 
may be seen (Fig. 149). 

CLINICAL EXAMINATION OF THE STOOLS. 

In order to make the clinical examination of the stools of 
benefit and satisfactory, we must have a standard for comparison. 







Fig-. 149. CoHective view of the feces. (Eyepiece III, objective 8A, 
Reichert.) a, muscle-fibers; b, connective tissue; c, epithelium; d, white 
blood-corpuscles; e, spiral cells; f-i, various vegetable cells; k, triple 
phosphate crystals in a mass of various micro-organisms; 1, diatoms. — 
Von Jaksch and Cagney: Clinical Diagnosis. 



Schmidt, of Dresden, has formulated a diet to meet this re- 
quirement, and it, or some modification, is now in general use 
by those following this line of work. There are two conditions 
for the satisfactory clinical examination of the feces: 

1. A knowledge of what a normal stool shoukl be under a 
certain diet. 

2. The methods of examination must be as simple as possible. 
1. The test-diet. — The requirements are: 

(a) That it must be nutritious enough to furnish calories 
sufficient for the body's need. 

(b) It must consist of such articles of food as can be ob- 
tained in any household. 



EXAMINATION O^ Fe:CE:S 297 

(c) It must contain a constant amount of certain articles, 
so that variation in digestion and absorption can be detected in 
the stool. 

Schmidt's diet is as follows: 1.5 liters of milk, 100 grams of 
zwieback, 2 eggs, 50 grams butter, 125 grams very rare or raw 
beef, 190 grams potato, and gruel from 60 grams oatmeal and 
20 grams sugar. 

This may be divided as follows : 

Breakfast. — Two eggs, half liter or two glasses of milk, one 
third the amount of zwieback and butter, or two slices of well- 
toasted bread, with butter, and the oatmeal and sugar. 

Dinner. — The steak and pototoes, one third zwieback and 
butter, and two glasses of milk. 

Supper. — Two glasses of milk, and the remainder of toast, or 
zwieback and butter. 

The amounts of each article should be measured or weighed 
accurately, and the beginning of the test-diet marked by giving 
a capsule containing carmine or charcoal, preferably the latter, 
because carmine would interfere with the color reaction in case 
an examination is made for blood in the stool. This diet should 
be given for several days. The first black stool will denote the 
length of time required for the passage of food through the gas- 
trointestinal tract. The examination of the stool consists of the 
following steps : The consistency, color, and smell must be ob- 
served. Then a piece of formed stool the size of a walnut, or 
an equivalent amount of liquid feces, is rubbed up in a mortar 
with distilled water until it is quite smooth and liquid. Part of 
this is poured upon a glass plate or a Petri dish, put over a dark 
background, and examined in a good light. 

In normal digestion, very little should be seen by the naked 
eye except small brown points (oatmeal), and occasionally sago- 
like grains that look like mucus, but which the microscope shows 
to be grains of potato. 

Pathologically, there may be : 

1. Mucus in large or small flakes which is not affected by 
rubbing up in the mortar. The smaller the flakes, the harder 
they are to recognize. They appear as glassy translucent flakes, 
often stained yellow by bile pigment. If at all doubtful, the 
microscopic examination will clear it up. 



298 DisKASKS o:^ the: rectum 

2. Pus, blood if considerable, can be easily detected, as can 
also parasites, stones, and foreign bodies. 

3. Remnants of muscle-fiber appear as small, reddish-brown 
threads, or small irregular lumps. When they can be easily 
seen by the naked eye and are quite numerous, it shows impair- 
ment of intestinal digestion. 

4. Remnants of connective tissue and sinew from the beef- 
steak can be detected from the mucus by their toughness and 
whitish-yellow color. If in doubt, a piece may be put on a slide 
with a drop of acetic acid and examined with the microscope. 
The connective tissue loses its fibrous structure, while the mucus 
becomes more threadlike. Small pieces of connective tissue can 
be found in normal stools, but when they are numerous and 
large their presence indicates the impairment of gastric digestion. 

5. Remnants of potato look like grains of boiled tapioca and 
may be confused with mucus. Any doubt of the nature of the 
particles can be cleared up by the microscope. 

6. Large crystals of acid phosphate of ammonium and mag- 
nesium occur in foul stools, and can be easily recognized by their 
shape and chemical reaction (solubility in all acids). 

MICROSCOPIC EXAMINATION. 

For microscopic examination, prepare three slides from the 
liquid feces. 

The first slide — a drop of the material to be examined under 
high and low power. 

The second slide — mix a drop of the material with a drop of 
acetic acid (U. S. P.), heating it to the boiling point, then put 
on the cover-glass. 

The third slide — a drop of the material with a drop of weak 
Lugol solution (iodin 1, KI 2, water 50). 

Normal stool — Slide one: 

(a) Single, small muscle-fibers, colored yellow, usually with 
a cross striation (Fig. 150). 

(b) Small and large yellow crystals of salts of fatty acids. 

(c) Colorless particles of soap (gray). 

(d) Single potato cells. 

(e) Particles of oatmeal. 

In the second slide a general idea of the fat content of the 



e:xamination 01^ i?e:ce:s 



299 



stool ca'n be obtained. Upon cooling, small flakes of fat acids 
can be seen. The large crystals of salts of fatty acids and the 
soap are broken up by the acetic acid, and fat acids are liberated. 
If the slide is heated again and examined while hot, the fat acids 
will be seen to run together in drops, which, as the slide cools, 
break suddenly apart. 

In the third slide, there should be violet-blue grains in some of 
the potato cells, and small, single blue points, probably fungi 
spores. 

Pathologically there may be. — Slide 1 : 

(a) Muscle-fiber in excess, perhaps with yellow nuclei. 

(b) Neutral fat drops or fatty acids in crystals. 

(c) An excess of potato cells with more or less well-preserved 
contents. 




Fig. 150. Muscle remnants in feces. 
large; b, medium; and c, small fragments, 
burger. 



(Leitz objective VII.) a 
-From Schmidt and Strass- 



(d) Parasite eggs, mucus, connective tissue, pus, etc. 
Slide 2: Fat acid flakes in excess. 

Slide 3 : Blue starch grains in potato cells or free oatmeal 
cells, fungus spores or mycelia. 



CHEMICAL EXAMINATION. 

Reaction. — The reaction of the stool is hard to get with 
litmus paper, but can be easily obtained by dropping a little 
softened fecal matter into 5 or 10 cubic centimeters of a weak, 
watery solution of litmus, shaking it and noticing the change. 
It is well to use another test-tube with the litmus solution only, 
as a control. The test should always be made with freshly 



300 



dise:ases 0^ the: rkctum 



passed feces, inasmuch as the reaction of the feces may change 
upon standing. 

Sublimate Test. — Consists of taking a few cubic centimeters 
of the Hquid feces and mixing it with an equal amount of 25 




Fig-. 151. Steele's modification of Strassburger's fermentation ap- 
paratus. It is constructed of perforated rubber corks, bent-glass tub- 
ing, and two test-tubes, each of 30 cubic centimeters capacity. The 
smaU glass tube D runs up to the top of the test tube C, to aUow for 
the escape of air, instead of the test-tube being perforated, as in 
Strassburger's apparatus. — Progressive Medicine, December, 1905. 



per cent watery solution of mercuric chlorid. A normal stool 
will turn a pinkish-red, indicating the presence of hydro-bilirubin, 
which will be more intense the fresher the material. A green 
color, even if it is detected microscopically, is pathologic and in- 
dicates unchanged bile pigment. 



KXAMINATION 01? I^ECE:S 301 

Fermentation Test. — About 5 grams of freshly formed feces 
are taken, or an equivalent amount of thinner material. Steele's 
fermentation apparatus, a modification of Strassburger's, is used. 
It is constructed of perforated rubber corks, bent glass-tubing, 
and two test-tubes of 30 cubic centimeters capacity (Fig. 151). 
A small glass tube beam runs up to the top of the test-tube (C) 
to allow for the escape of air. 

The stool is rubbed up with sterile water and poured into the 
main bottle (A). 

This is filled with sterile water; tube B is filled with water and 
fitted in place, and tube C is then fitted on empty-. The reaction 
is carefully noted before the test is started. The apparatus is 
then stood in a warm place for 24 hours, best in an incubator at 
37° C. If gas forms by fermentation in A, it will rise into B, 
and the amount will be indicated by the water displaced 
into C. Normally, the fermentation test should show practically 
no gas, and the original reaction should be unchanged for 24 
hours. If more than one third of the tube C is filled, it is 
pathologic. If, then, the reaction is decidedly more acid, it is a 
carbohydrate fermentation ; if alkaline and with a foul smell, it 
is a fermentation of albumins. 

Estimation of Lost Albumin Residue. — A qualitative test may 
be made as follows : 

A softened portion of the stool is filtered; the filtrate shaken 
with silicon and refiltered ; then it is saturated with acetic acid 
to bring down the nucleo-proteids ; after filtration a drop of 
ferrocyanid solution is added. A decided precipitate indicates 
albumin. 

It was formerly thought that a positive test shows a diminu- 
tion of albumin digestion, but the work of recent investigators 
would indicate that this is not the case. Under pathologic con- 
ditions, the nucleo-proteids may be decidedly increased, although 
their presence is not characteristic of any particular disease. 
Other forms of albumin are rarely found in the feces, even after 
the ingestion of excessive amounts. The occurrence of albumin 
in the feces of adults is almost always associated with diarrhea, 
and usually with an excessive formation of mucus. It usually is 
serum-albumin, much less frequently albumoses. Such ''lost 
albumin" in the stools indicates severe anatomical changes in the 



302 



dise:ase:s o^ the: re:ctum 



bowel, but usually not disturbance of absorption. The albumin 
under these circumstances comes from the intestinal wall, and 
sometimes a part of it may be digested by the intestinal fer- 
ments into albumoses. 







Fig-. 152. Mucus shreds. — From Schmidt and Strassburger. 




Fig. 153. Mucus shreds after the addition of acetic acid. — Hensel, 
Weil, and Jelliffe: Urine and Feces in Diagnosis. 



CLINICAL SIGNIFICANCE OF TEST. 

Mucus. — There are two conditions in which the presence of 
mucus in the stools has no significance : when hard, dry masses 
of feces are covered with thin mucus, without evidence of rectal 
inflammation ; and when it is discharged in casts, the so-called 
mucous colic. Otherwise it indicates inflammation of the in- 
testinal mucous membrane. If it is densely impregnated with 



^EXAMINATION 0? FIECEES 



303 



bacteria, food remnants, and detritus, the origin of the inflam- 
mation is probably high up in the intestine (Figs. 152, 153). 

Bilirubin. — Bihrubin discoloration affords no certain evi- 
dence of inflammation of the small intestine, but the presence of 
bilirubin granules and crystals in a cellular arrangement is sug- 
gestive. 

Semidigested Cells. — The presence of semidigested cells or 
of their nuclei indicates an origin high up in the bowel. 




Fig-. 154. Hematoidin crystals from acholic stools. (Eyepiece III, 
objective 8A, Reichert.) — Von Jaksch and Cagney. 




Fig-. 155. Acholic stools. (Eyepiece III, objective 1-15, oil immer- 
sion, Reichert, Abbe's mirror, narrow diaphragm.) — Von Jaksch and 
Cagney. 

Hyaline Cells. — The presence of hyaline cells favors the as- 
sumption that an inflammation of the colon exists. 

Bile Pigment. — A green color of part or all of a stool, by 
the sublimate test, is pathologic, except in children. It means a 
too short period of passage through the intestine, and that time 
for a normal reduction process of the bilirubin into hydro-biliru- 
bin was lacking. A normal fresh stool will give a pink color 
with mercuric chlorid. If a color reaction of any kind is ab- 



304 DISE^ASES OF THE RE^CTUM 

sent, it indicates a very fat stool, or an absence of bile in the 
intestine (Figs. 154, 155). 

The assumption of the temporary stoppage of the bile does 
not account for all of the cases of colorless feces which do not 
darken on exposure. The pathologic conditions in which color- 
less feces without jaundice may occur comprise defective supply 
of bile to the duodenum, intestinal catarrh, tuberculous abdominal 
disease, malignant disease of the intestine, septic diseases (es- 
pecially those which affect the abdomen), chlorosis, and leu- 
cemia. 

Fat. — It will need a little practice to tell, by the use of the 
diet, whether there is an increase of fat in the stool. As the 
normal amount of fat in the feces varies between wide limits, 
only a considerable excess of fat can be detected. 

Remnants of Meat. — Normally there should be only micro- 
scopic particles of connective tissue and muscle-fiber. An excess 
of either is often visible to the naked eye, but need not be macro- 
scopic to be pathologic. 

Excess of Connective Tissue. — This indicates insufficient 
gastric digestion, because such fibrous tissue is only digested by 
the gastric juice. The meat should be rare, to give this test its 
full value. If motility is increased, there may be an excess of 
this in hyperacidity. 

Excess of Undigested Muscle-Fiber. — This indicates intes- 
tinal indigestion and probably means trouble in the upper part 
of the small intestine; but whether the trouble is in the trypsin 
of the pancreatic secretion, or the activating principle (entero- 
kinase) of the intestinal juice, or in increased peristalsis, we 
can only judge from other symptoms. When the gastric juice 
fails to digest away the framework of the muscle-fiber, giving 
the intestinal juices no chance to do their work, connective tissue 
and muscle-fiber are often found. This occurs often in acute 
gastric catarrh. 

Pathologic Carbohydrate Fermentation. — This means poor 
starch digestion and indicates, as a rule, disturbance in the small 
intestine, and usually is due to insufficiency of the succus enteri- 
cus. 

Pathologic Albumin Fermentation. — This means a large 



EXAMINATION O^ I^ECES 305 

residue of albumin in the feces and indicates usually some ana- 
tomical change in the mucous membrane of the small intestine. 

Pus. — This can be rarely recognized in the stool unless it 
comes from the lower part of the large bowel ; if it comes from 
high up in the intestine, it is rapidly changed. 

Blood in the Stools. — The presence of blood in such quan- 
tities as to be visible is considered in Chapter II, so I will only 
consider the so-called occult blood in the stools. The presence 
of occult bleeding from the gastrointestinal tract is a symptom of 
much importance, provided various sources of error can be 
eliminated. It has the same clinical significance as visible hemor- 
rhage, and its presence is of decided diagnostic value, chiefly 
in the detection of gastric or duodenal ulcer, or gastrointestinal 
cancer, because it occurs with considerably more regularity and 
frequency in these affections than in any other condition of the 
gastrointestinal tract. 

The value of this sign depends entirely upon the care with 
which the various sources of error are eliminated, and if the re- 
action is positive, will be of value in the diagnosis of cancer or 
ulcer of the gastrointestinal tract only when sources of bleeding 
that have no significance are excluded. On the other hand, after 
repeated examinations, if occult blood is not found, then cancer 
or ulcer can be excluded. Since the test is very sensitive (very 
small amounts can be detected), the chance for error in deter- 
mining the origin of the hemorrhage is greater than in large and 
visible hemorrhages. Observations have shown a positive re- 
action in the feces on the ingestion of 0.5 grams of blood. It 
is possible to exclude the source of the blood when in the lower 
bowel by the use of the proctoscope, etc. Tuberculous ulcer, 
typhoid fever, hemorrhoids, fissure, and purpura can be easily 
excluded; other conditions, however — e. g., cirrhosis of the liver 
with slight symptoms — may be the cause of error. Red beets, 
carmine, swallowed blood from any cause, hemoptysis, epistaxis, 
menstruation, cirrhosis of the liver, purpura, benign stenosis with 
stagnation, tuberculous enteritis, cancer of the gastrointestinal 
tract, gastric or duodenal ulcer, typhoid ulcer, hemophilia, hem- 
orrhoids, ulcer, fissure, and fistula of the anus and rectum are a 
partial list of conditions which may give a positive reaction with 
the various tests. 



306 DISE^ASKS 01^ THE RECTUM 

When testing for occult blood it is best to have the patient on 
a diet free from meats and meat juices and to give a good-sized 
capsule of charcoal; the first black stool will mark the feces 
following the meat-free diet. 

A number of different tests are used for the detection of occult 
blood; probably the Weber test, with its various modifications, 
is the one most employed. It is well, however, to use a control 
test, preferably Klunge's aloin test. If both tests give a positive 
reaction, there is no doubt but that there is blood in the stools. 
The latter is not liable to be obscured by bile pigments or chloro- 
phyll, in the ethereal extract, and is extremely delicate. 

Weber's Test. — Take 2 or 3 grams of feces, mix thoroughly with 20 
cubic centimeters of water; extract with 20 cubic centimeters of ether 
to remove fats. Then use one-third the volume of acetic acid and 
shake well; add 10 cubic centimeters of ether and shake well. If 
ether does not come to the top soon, add a few drops of absolute alcohol. 
To 2 cubic centimeters of the ethereal extract, add 10 drops freshly- 
prepared tincture of guaiac and 10 to 20 drops of ozonized turpentine. 
Care must be taken that all utensils are absolutely clean and free 
from water. If blood is present, an intense blue color appears, gradu- 
ally assuming a reddish-violet tint. 

Klunge's Aloin Test. — Take a small quantity of aloin, mix with 
3 to 5 cubic centimeters of 70 per cent alcohol. Four to five cubic 
centimeters of acetic acid ethereal extract is tried with 20 to 30 drops 
of ozonized turpentine and 10 to 15 drops of the aloin solution. If 
blood is present, a bright-red color appears, which turns to a cherry- 
red on standing. If blood is not present, a yellow color remains for 
an hour or two, then becomes pink. It may take 15 or 20 minutes 
to get a positive reaction. 

Holland's Modification of Weber's Test. — Instead of using ozonized 
turpentine, Holland uses sodium perborate (Shering) in tablet form; 
a few drops of the acetic acid-ether mixture is placed upon a small 
piece of tablet of perborate of sodium, and a drop or two of the tinc- 
ture of guaiac is cautiously brought into contact with it, preferably 
on a white plate. If blood is present, the perborate turns blue in a 
few minutes and remains blue until the drying of the tincture of guaiac 
leaves a yellow residue which changes the blue to green. If the pro- 
portion of blood is small, the perborate turns a pale blue, which turns 
green as the guaiac dries. 

Benzidin Test. — A little benzidin and about 2 cubic centimeters 
glacial acetic acid are shaken up together and set aside for the benzidin 
to dissolve. A piece of feces the size of a bean is stirred into a test- 
tube about one-fifth full of water; the tube is plugged with cotton, 
and the suspension of fecal matter is heated to a boiling point over 



EXAMINATION OF FECl^S 



307 



a flame. About 10 or 12 drops of the concentrated benzidin solution 
are poured into another test-tube, from 2 to 2.5 cubic centimeters of 
a 3 per cent solution of peroxid of hydrogen added. One or two drops 
of the boiled suspension of feces are then added to this mixture. If 
blood is present in the feces, this brownish fluid turns green or blue; 
the more blood the more the test inclines to blue. The color reaction 
occurs within two minutes in the presence of blood and turns to a 
dirty-purple in nve to fifteen minutes. If there is no blood present, the 
dirty-brown color remains unaltered. 

Gallstones. — In cases of colicky abdominal pain, the feces 
should always be examined for biliary concretions. The best 
way to search for gallstones is to put the feces in a fine sieve 
and wash the stool with running water from a faucet, if possible. 
The concretions vary in size from as small as the head of a pin 
to the size of a pigeon's Qgg. They may be seen as small 
crumbling masses, as hard stones presenting an irregular con- 






Fig-. 156. Gallstones. 



tour, or as smooth facets (Fig. 156). The larger stones are not 
passed by the bowel unless perforation has occurred into the 
intestine. The composition of the calculi varies. Some are com- 
posed of cholesterin; some of inspissated bile; and others of 
calcareous salts. Those composed of cholesterin are the most 
common and are somewhat soft, and white, grayish, bluish, or 
greenish in color. I think that the consensus of opinion inclines 
to the belief that the nucleus of the majority of gallstones is 
clumps of bacteria, either colon or typhoid bacilli, al- 
though it may be composed of earthy sulphates or phosphates. 
Calculi which consist largely of biliary pigments are brown in 
color, hard, and heavier than water; those composed of cal- 
careous salts are generally irregular and rough. 

Intestinal concretions, or enteroliths, are rare. At times their 



308 



dise:asks of the; rectum 



nucleus consists of some foreign body like a fruit seed, upon 
which calcium and magnesium salts have become deposited. 

Intestinal sand is hard, gritty, pale brown to black in color, 
readily sinks in water, and is usually composed of the salts of 
calcium magnesium and ammonium. Sometimes silica is pres- 
ent. ! , 

ANIMAL PARASITES. 

Protozoa. — Of the protozoa, the amebse (Chapter XIII) are 
the most important in the etiology of intestinal disease. It is 
possible to find amebae in the stools of perfectly normal indi- 




Fig-. 157. Amoeba coli. — Simon: Clinical Diagnosis. 



viduals, and they increase in number as the stools become more 
alkaline in reaction. 

AmcEba Coli. — In certain forms of dysentery the Amcebcc coli 
occur in the stool in enormous numbers, chiefly embedded in the 
mucus. They are also found on pathologic examination in the 
ulcers in the intestines. In examining, the stool must be fresh, 
as the amebse very rapidly die off in a stool that has been pre- 
served but a few hours. A particle of mucus, preferably blood 
streaked, is taken from a fresh stool and placed on a chemically 
clean slide, better, a warm stage. In adjusting the cover-glass, 
a horsehair or some similar object should be placed between it 
and the slide, in order not to crush the organisms or interfere 
with their locomotion. Examine with a low-power microscope. 



EXAMINATION 0^ FECES 



309 



They are from 10 to 50 micromillimeters in size. When at rest, 
their outHne is, as a rule, circular or ovoid; when in motion, 
they present one or more arm-like prolongations, "the pseudo- 
podia." The protoplasm can be differentiated into a translucent, 
homogenous ectosarc or mobile portion and a granular endosarc 
containing the nucleus, vacuoles, and granules (Fig. 157). As 
a rule, one or two vacuoles are present, the edges of which are 
not infrequently surrounded by fine, dark granules. 

BaIvAntidium Coli. — Another form of protozoon, that is an 
etiologic factor in certain forms of dysentery, is the Balantidium 
coli. This organism is a harmless inhabitant of the colon of the 
pig, and it is supposed, is transferred to human beings through 
sausages (Fig. 158). The parasite is of oval shape, 60 to 100 




Fig-. 158. Balantidium coli. — 1 and 2, stages of division; 3, con- 
jugation. — After Leuckart, Progressive Medicine, December, 1905. 

microns long and 50 to 70 broad, and is covered with cilia that 
are in rapid motion when the organism is alive. Ectosarc and 
endosarc are sharply dift'erentiated. The endosarc is granular 
and contains a kidney-shaped nucleus, generally two contractile 
vacuoles, and granular detritus. Motion is so rapid that it can- 
not be followed under the microscope. The protozoon dies very 
quickly and undergoes fragmentation. 

There are other forms of protozoa, but their role in the 
etiology of intestinal diseases is not definitely settled. 

Worms. — The diagnosis of helminthiasis from the stools 
may be very easy, or it may require considerable painstaking re- 
search. If segments of the tenia pass in the stools, the diagnosis 
is quite evident. In other cases, a diagnosis can only be made by 
finding the ova in the feces. To examine for the ova, take a small 



310 



dise:asks o^ the rectum 



amount of feces from different parts of the stool, dilute it very 
much with sterile water, and centrifuge repeatedly. After each 
centrifugalization, the supernatant dirty water is thrown away, 
and fresh water is added, the whole shaken up and again placed 
in the centrifuge, this to be repeated five or six times. In this 
way all bacteria, free coloring matter, light vegetable matter, 
etc., are removed, and only heavier particles, including any 
ova that may be present, will remain and can be easily and sat- 




Fig-. 159. Ascaris lumbricoides. a, the worm; b, the head; c, egg; 
a, half natural size; b, slightly magnified; c, eyepiece 1, objective 8 A, 
Reichert. — Von Jaksch and Cagney: Clinical Diagnosis. 



isfactorily examined under a low power of the microscope. There 
is left no obscuring cloud of bacteria or fine granular debris, 
but instead, each ovum, or muscle-fiber, or crystal stands out 
sharply and clearly. 

Nematodes. — Nematodes are round worms. Those found in 
the human being are: 

1. Ascaris lumbricoides is the most common parasite of the 
human intestinal canal. They are found chiefly in the small 
intestines but may find their way into the stomach, the bile pas- 



EXAMINATION 01^ ^ECES 



311 



sages, or out at the. anus. Clumps of them have been known to 
cause intestinal obstruction. 

The worm is cylindrical, the male being from 10 to 25 centi- 
meters in length, the female from 25 to 40 centimeters. The 
head consists of three projections or lips, which are provided 




Fig-. 160. Oxyuris vermicularis. a, sexually mature female; b, 
female filled with eg-g-s; c, male. Magnification, XIO. — After Heller, 
from Zeigler. 



with suckers and fine teeth. The tail end of the male is rolled 
up on its ventral surface like a hook and is provided with 
papillae. The genital aperture of the female is situated directly 
behind the anterior third of the body. The eggs are yellowish- 
brown in color, almost round, and measure 0.06 millimeters by 



312 



dise:ase:s of the rectum 



0.07 millimeters in size. They are surrounded by an irregular 
albuminous envelop, which is covered by a tough shell ; the con- 
tents are coarsely granular (Fig. 159). 

2. Oxyiiris vermicularis (common threadworm, seatworm, pin- 
worm, etc.) is a very frequent parasite, especially in young chil- 
dren, often passing from the anus into the vulva in female chil- 
dren and setting up considerable irritation in the vagina. The 
male is 4 millimeters, the female 10 millimeters, long. At the 
head three lip-like projections with lateral cuticular thickenings 
may be seen. The tail of the male is provided with six pairs 
of papillae, and the female with two uteri. The eggs are 0.05 
by 0.02 to 0.03 millimeters in size, and covered with a membrane 





Fig-. 161. Oxyuris vermicularis. la, 
2, magnified. — Hensel, Weil, and Jelliffe: 



male; lb, female, natural size; 
Urine and Feces in Diagnosis. 



showing a double or triple contour. In the interior, which is 
coarsely granular, the embryo is contained. The ova do not 
occur in the feces (Fig. 160, 161). 

Ankylostonia duodenale, or Dochmius duodenalis, or Strongylus 
duodenalis is generally described in America as Uncinaria. It 
was formerly supposed that this parasite was found only in the 
Old World and only brought into this country, but it has been 
demonstrated that there are many endemic cases in our Southern 
states. 

There are certain differences between the American and Old 
World parasite. 



i:XAMINATlOX OF FE;CES 



313 



Stiles^ gives the following description : 

Vncinnria duodenalis. — The Old World hookworm. Body cylindrical, 
somewhat attenuated anteriorly; buccal cavity with two pairs of 
ventral teeth curved like hooks, and one pair of dorsal teeth directed 
backward; dorsal rib not projecting into cavity. Male 8 to 11 milli- 
meters long, caudal bursae with dorso-median lobe and prominent lateral 
lobes united by a ventral and slender. Female, 10 to 11 millimeters 
long; vulva at or near posterior third of body. Eggs ellipsoid, 52 
to 60 micromillimeters by 32 micromillimeters, laid in segmentation. 
Development direct without intervening host (Fig. 162). 

Uncinaria americana. — The New World hookworm of man: Body 
cylindrical, somewhat attenuated anteriorly; buccal capsule with a 



b a 




Fig. 162. Anklostomum duodenale. — Von Jaksch and Cagney. 

a. Male (natural size). 

b. Female (natural size). 

c. Male (magnified). 

d. Female (magnified). 

e. Head (eyepiece II, objective C, Zeiss). 

f. Eggs. 



dorsal pair of prominent semilunar plates or lips and a ventral pair of 
slightly developed lips of same nature; dorsal conical median tooth 
projects prominently into buccal cavity. Male 7 millimeters long, 
caudal bursse with short dorso-median lobe, which often appears as if 
it were divided into two lobes, and with prominent lateral lobes united 
ventrally by an indistinct ventral lobe; common base of the dorsal 
and dorso-lateral rays very short; dorsal ray divided to its base, its 
two branches being widely divergent, and their tips being bipartite; 
spicules long and slender. Female 9 to 11 millimeters long; vulva 



iBulletin No. 10 Hygienic Laboratory, U. S. Public Health and Marine 
Hospital Service. 



314 



dise:asi:s 01^ THt re:ctum 



in anterior half of body but near equator. Eggs ellipsoid, 64 to 76 
micromillimeters long by 36 to 40 micromillimeters broad, in some 
eases partially segmented in utero; in others containing a fully de- 
veloped embryo oviposited. 

The eggs of the American species are much larger than those 
of the Old World species. The eggs have a transparent shell 
with a linear contour and are often found in enormous quan- 
tities in the feces. A rather peculiar fact is that the ova of un- 
cinaria, although sticking closely to the glass slide, do not seem 
to adhere to any of the other constittients of the stool. When 
a drop of washed sediment feces is allowed to remain on the 




Fig-. 163. Trichocephalus dispar. a. male; b. female; c, eggs; a, b, 
slightly mag-nified; c, eyepiece II, objective 8A, Reichert. — Von Jaksch 
and Cagney. 

slide for a few minutes and then gently immersed in water and 
examined microscopically, the eggs are found adhering to the 
slide, and all else has been washed away. In suspected cases 
where the diagnosis is difficult, a full dose of thymol may make 
it clear, causing the appearance in the stool of the parasite, 
which appears as a thread-like body, a half to three quarters of 
an inch long, grayish-red in color. Its habitat is the jejunum and 
duodenum. Infection takes place through contaminated drink- 
ing water. 

For persons who are not in a position to make a microscopic 
examination, the blotting-paper test will be found very useful. 



EXAMINATION OF FECES 



315 



To make the test, use only fresh feces. Place an ounce or more 
of the stool on a piece of white blotting paper, allowing it to 
remain for 20 to 60 minutes ; remove the feces, and examine the 
color of the stain. In about 75 per cent of the cases of medium 
or severe uncinariasis, the stain is a reddish-brown, resembling 
somewhat a blood stain. In making this test on anemic patients, 
hemorrhoids must be excluded. 

Trichocephalus dispar, or ''whip worm," frequent in most parts 




Fig-. 164. Trichince. — Von Jaksch and Cagney. 

a. Male intestinal trichina (slightly magnified). 

b. Female intestinal trichina (slightly magnified). 

c. Trichina of muscle (eyepiece III, objective IV, Reichert). 



of the world, gets its name from being formed like a whip, the 
lash end being the head end, while the tail end is very much 
thicker. The male measures 46 millimeters and the female 50 
millimeters in length. The eggs are brownish in color, 0.05 by 
0.06 millimeters in size, presenting a double-contoured shell with 
a depression at each end, closed by a lid. The contents are 
coarsely granular. Its habitat is in the cecum ; the living worm is 
rarely found in the feces (Fig. 163). 



316 



dise:ase;s of the rectum 



Trichina spiralis. — The male is 1.5 millimeters in length, and 
the female 3 millimeters. The male has four prominent papillae, 
situated between the conical protuberances at the extremity. The 
female's sexual organs consist of a tubular ovary which is placed 
at the hinder part of the body and a tubular uterus with which 
the ovary communicates in front. Impregnation takes place in 
the intestine. The eggs develop into embryos while still in the 
uterus, and the newly born parasite almost immediately perforates 
the intestine and becomes imbedded in the muscles of its host. 
The mode of infection is through imperfectly cooked pork. 




Fig-. 165. Ang-uillula stercoralis. — Von Jaksch and Cagney. 

a. Female. 

b. Male. 

c. Head (eyepiece II, objective 8 A, Reichert). 

Rarely is the parasite found in the stools. In suspected cases 
an anthelmintic may cause the expulsion of the mature worm 
in the stool. Eosinophilia is a constant accompaniment of the 
presence of trichina (Fig. 164). 

Anguillula intestinalis is 2.25 millimeters in length and 0.04 
millimeters in thickness at its middle. It has a triangular mouth 
closed by three lips. Its vulva lies at the junction of the middle 
with the posterior third. Its habitat is the small intestines. The 
eggs resemble those of Anklostoma duodenale, but are longer, 
more elliptical, and pointed at the poles. In recent stools the 



EXAMINATION O^ FKCKS 317 

larvae alone can be seen. When sexually mature, it is known 
as Anguillula stercoralis; the body is round; it shows faint traces 
of transverse striation. The head is of the form of a blunt cone 
and sessile on the body, and is furnished with two lateral jaws, 
each bearing a pair of teeth. The male is 0.88 millimeters and 
the female 1.2 millimeters long. Little is known concerning the 
manner of infection. Thayer reported the first case of infection 
by this worm in the U. S. (Fig. 165). 

Cestodk Worms. — Cestodes are popularly known as tape- 
worms. Externally they are long, flattened, segmented worms. 
The head is derived from the embryo contained in the flesh of 
the various domestic animals which are used as food. By bud- 
ding it gives rise to all of the succeeding segments, which are 
morphologically the same, diminishing in size toward the head. 




Fig-. 166. Head of Taenia solium.— X45 (Leuckart). 

Tccnia solium. — The tapeworm derived from pork may be two 
to three meters long. Head quadrilateral, about as large as a 
pinhead ; it has four prominent suctorial discs, usually pigmented, 
and between them a rounded elevation which is surrounded with 
about 26 booklets of different sizes, and is dark in color. This is 
succeeded by a delicate thread-like neck, about one inch in length 
and un jointed. The segments or proglottedes are short and rela- 
tively broad near the neck ; the average length of the mature seg- 
ments is from 9 to 10 millimeters, and the breadth is 6 to 7 mil- 
limeters. Each segment contains a uterus having five or seven 
branches. The ova are round, of a brownish color, and sur- 
rounded with a thick radially striated membrane ; in their in- 
terior the booklets of the embryos can usually be made out (Fig. 
166). 

Tcenia saginata (Medio canniilata). — The most frequent tape- 



318 



DISE^ASKS OF THE RKCTUM 



worm of Europe and America, infection taking place through 
measly beef. It is from 4 to 8 meters long. The head is sur- 
rounded with four large and usually black-pigmented suckers, but 




Fig-. 167. Taenia saginata. — Simon: Clinical Diag^nosis. 

a. Natural size. 

b. Head much enlarged. 

c. Ova much enlarged. 



is not provided with a rostellum, and is without a circle of booklets. 
Segments are rather thick and opaque, and each is provided with a 
very much-branched uterus which opens laterally. The ova are 



EXAMINATION OF FKCKS 



319 



elliptical in form, of a brown color, and usually inclosed in a 
distinct vitelline membrane. In the interior the embryos are 
seen embedded in a brown granular material (Fig. 167). 

Tcenia nana. — Occurs rarely in America, mostly in Southern 
Italy. It is 7 to 15 millimeters long. It occurs in large numbers, 
and is usually located in the lower part of the ileum. It has four 
suckers and a crown of booklets. The segments are of a yellow- 
ish color and about four times as broad as long. The uterus is 
oblong and contains numerous ova, having two distinct mem- 
branes. In the interior of the egg may be seen the embryo al- 
ready provided with five or six booklets. Infection probably oc- 
curs from man to man. The parasites may be present in great 
numbers in the intestines, producing severe nervous symptoms, 
SLich as epileptic seizures, insensibility, mental derangements, etc. 





Fig. 168. Head of Bothriocephalus latus. (Eyepiece III, objective 
IV, Reichert.) — Von Jaksch and Cagney. 

a. Seen on edge. 

b. Seen on the flat. 

c. Proglottides. 

d. Eggs. 



Bothriocephalus latus. — The longest of the human tapeworms 
has been found in the United States in only a few imported cases. 
The larv?e have been found in various fishes. It is from five to 
eight meters long and tapers toward both extremities. The 
largest segments measure 35 millimeters in length, 10 to 12 mil- 
limeters in breadth. The head is ovoid, 25 millimeters long and 
10 millimeters broad, somewhat flattened, and provided in each 
lateral aspect with a groove-like sucking apparatus. The uterus 
is a slightly convoluted canal. The eggs are ovoid, 0.07 mil- 
limeters by 0.045 millimeters, and possess a thin brown capsule 
and open by a small lid at one end. This parasite may be the 
cause of severe anemia (Fig. 168). 



320 dise:asp:s of the rectum 

CHARACTER OF FECES IN CERTAIN INTESTINAL 
AFFECTIONS. 

Acute Intestinal Catarrh. — This follows the ingestion of ex- 
cessive quantities of normal food or tainted food, beer and cer- 
tain poisons, acids or alkalies, arsenic, corrosive sublimate, etc., 
when taken in proper quantities ; also find it in cholera nostras, 
typhoid fever, severe malaria, and in diseases of heart, lungs, 
and liver due to disturbance in circulation. The frequency of 
the stools depends largely upon the seat of the lesion, involve- 
ment of the large intestine, especially the transverse and descending 
colon, causing the bowels to move more frequently than trouble 
higher up. There may be from 10 to 15 passages a day. On the 
other hand, isolated catarrh of the small intestine may exist 
without giving rise to diarrhea. The stools at first are semi- 
solid, but rapidly become liquid, often foul-smelling, and asso- 
ciated with gas. The higher in the bowel the lesion, the more 
odor and gas. The color varies from a light to a dark brown. 
If the trouble exists in the small bowel only, the stools are firm, 
formed, and contain particles of hyaline mucus, visible only upon 
microscopic examination. They usually contain particles of undi- 
gested food. If the colon is afifected, the stools are loose. Ex- 
tensive involvement of the colon is usually accompanied by mucus 
in large quantities. 

Chronic Inflammation of the Intestine. — May follow an 
acute attack, or may follow some of the infectious diseases. 
Diarrhea usually alternates with constipation. Rarer is con- 
tinuous diarrhea or constipation. The feces present the same 
characteristics as the acute inflammations. 

Diptheritic Enteritis. — Always diarrhea, often with tenes- 
mus. Stools fluid, with occasional passage of formed feces. 
They consist mostly of pus, blood, and mucus, and some necrotic 
tissue may be found. 

Mucomembranous Colitis. — No frequency in number of 
stools; may have constipation. Stools are composed largely of 
tough leathery mucus, which may present casts of the bowel. 
This may be transparent or gray and semiopaque, or may be 
brown (from fecal matter), or red (blood). 

Cholera Nostras. — An infectious disease afifecting both the 



EXAMINATION OF F'ECES 321 

Stomach and bowels. The stools are first feculant, but soon be- 
come colorless and more and more watery, until they resemble 
the so-called "rice-water'' stools of Asiatic cholera, and contain 
serum-albumin and mucin. 

Dysentery. — Stools are large and frequently composed of 
pus, mucus, and blood, fluid or semifluid ; may find necrotic 
masses of mucous membrane. 

Amebic Dysentery. — Stools are frequent fluid, and may con- 
tain large amounts of mucus, frequently stained with blood; 
reaction always alkaline. Microscopic examination of the fresh 
mucus shows epithelial and red blood-cells and the ameba. 

Carcinoma of the Small Intestine. — The stools of wdiich have 
no distinctive feature. 

Carcinoma of the Rectum and Sigmoid. — This is taken up 
elsewhere in this volume (Chapter XVI). 



INDEX OF AUTHORITIES QUOTED 



Adler, L. H., Jr.. 108 
Albutt, 222, 223 
Alexander of Tralles, 214 
Andrews, 195 
Aretaeus, 214 
AsMon, 50 
Ayers, 215 

B 

Ball, 18, 21, 24. Ill, 114, 161 
Beck, Emil G., 55, 156 
Benivieni, Antonio, 214 
Beranger and Feraud, 237 
Boas, 287 
Brewster. 267 



Casagrandi and Barbagalli, 223 
Celsus, 214 
Cetti, 294 

Corsons, E. A., 252 
Councilman, 230, 233 
Councilman and Lafleur, 214, 222 
Cripps, 26, 107, 156 
Crisler, J. A., 252 
Crossen, 46 
Czernicki, 216 



G 

Galen, 214 

Gant, 26, 107, 108 

Griswold, V. M., 265 

H 

Hamilton, E. A.. 109 

Hanes, Granville, S., 64, 245 

Harris, H. E., 214, 228, 245, 252 

Heller, 311 

Hensel, Weil, and Jelliffe, 302, 312 

Hertzler, 266 

Hertzler, Brewster, and Rogers, 

265 
Hippocrates, 214 
Hirsch, A., 215 
Hirst. 48 
Holl, 25 



Jelks, John L. 
Jurgens, 222 



206, 214, 227 



K 



Kartulis, 214, 243 
Kelly. 63 
Kelsey, 107, 175 
Krouse, Louis J., 115 



D 

Dixon, Prof. A. F., 18 
Dudley. 47 



Le Roy, Louis, 249 
Leuckart, 309, 317 



Fleumer, O. C, 253 
Flexner, 214. 220 
Flexner and Strong, 219 
Franck, 175 



M 

McDill, 214, 243 

McGregor, 215 

MacMillan, 85 

Martin, Thomas Charles, 20, 58, 91 



323 



324 



INDKX OF AUTHORITIES QUOTED 



Maurel, 294 
Meyer, 252 
Montgomery, 50, 102 
Murray, D. H., 109, 249 



Osier, 214, 215, 221, 245 



Schmidt, 296 

Schmidt and Strassburger, 299, 

302 
Shiga, 214, 219, 220 
Simon, 308, 318 
Steele, 301 

Sternberg, Surgeon General, 214 
Stiles, 313 
Strassburger, 301 
Strauss, 294 
Strong and Musgrave, 214, 230, 

233, 245 



Teachnor, Wells, 86 
Thayer, 318 
Thevenol, 217 
Thibault, Henry, 265 
Thomas, 214 
Thompson, 25 
Thompson and Ball, 23 
Tuttle, 29, 63, 107, 129, 205, 207, 
209, 211, 214, 229, 252 



Von Jasch and Cagney, 295, 296, 
303, 310, 314, 315, 316, 319 

W 

Wagner, George W., 293 
Wallis, 108, 156, 199 
Weir, Robert, 252 
Woodward, 214, 216 



INDEX 



Abscess, ischiorectal, 51, 137 
diagnosis of, 138 
incision of, 139 
symptoms of, 137 
treatment of, 138 
intermural, 134 
diagnosis of, 135 
proctoscopic view of, 135 
treatment of, 136 
marginal, 131 

examination of, 133 
symptoms of, 132 
treatment of, 133 
of the anorectal region, 129, 140 

classification of, 129 
perianal, local anesthesia for, 

276 
perineal, 130 

diagnosis of, 131 
treatment of, 131 
rectal, 289 
subtegumentary, 131 
examination of, 133 
symptoms of, 132 
treatment of, 133 
tegumentary, 130 
diagnosis of, 131 
treatment of, 131 
Acarus scahei as cause of pruri- 
tus ani, 101 
Adrenalin in treatment of hemor- 
rhoids, 174 
Albolene, liquid, for acute proc- 
titis, 206 
for constipation, 89 
for fecal impaction, 98 
for hemorrhoids, 186, 190 



Amebse, examination of feces for, 

225 
Amebic dysentery, 220 

character of feces in, 321 
chronic, 248 
secondary, 248 
Amrjcba coli mitis. 223, 224, 308 
dysenterice, 222 
histolytica, 222, 223 
Anal canal, anatomy of the, 17, 18 
fissure, 117, 128 
cause of, 117 
diagnosis of, 120 
from tearing-down of crypt 

of Morgagni, 119 
local anesthesia for, 276 
multiple, 118 
treatment of, 121 

author's operation in, 126 
excision in, 121 
ichthyol in, 121 
incision in, 124 
injection in, 123 
nitrate of silver in, 121 
ointment in, 122 
scarlet-red ointment in, 122 
suppositories in, 122 
surgical, 123 
with sentinel pile, 117 
fistulas, 141, 158, 290 
blind external, 153 
treatment of, 154 
blind internal, 154 
diagnosis of, 154 
treatment of, 155 
direct complete, 146 
excision of, 150 
horseshoe, 142 



325 



326 



INDEX 



Anal fistulge — cont'd. 

in tuberculous patient, 157 
diagnosis ot 158 
symptoms of, 158 
treatment of, 158 
incision of, 148 
injection of bismuth paste in, 

156 
ligature operations for, 151 
local anesthesia for, 276 
mucocutaneous, 156 
multiple complete, 147 
simple complete, 142 
diagnosis of, 113 
symptoms of, 142 
treatment of, 148 
submucous, 156 

tract, 156 
varieties of, 141 
papillae, anatomy of, 19, 195 
hypertrophy of, 193-198 
local anesthesia for, 277 
ulcer, 128 

excision of, 128 

after-treatment of, 128 
Anatomy, 17-29 

of the anal canal, 17, 18 

papillae, 19, 195 
of the anus, 17 
of the coccyx, 24, 26 
of the columns of Morgagni, 22 
of the crypts of Morgagni, 19 
of the folds of Houston, 22 
of the ischioretcal fossa, 26 
of the ligaments, 25 
anococcygeal, 25 
lateral, 25 
of the mesosigmoid, 27 
of the muscles, bulbocavernosus, 
18, 24 
gluteus maximus, 24 
iliococcygeus, 23 
levator ani, 23, 24 
pubococcygeus, 24 
puborectalis, 18, 25 
rectourethralis, 18, 23 
sphincter, recti, 25 



Anatomy of the muscles — cont'd. 
external, 18, 191, 24 
internal, 18, 20, 23 
transversus perenei, 24 
of the rectal valves, 22, 91 
of the rectum, 18, 20, 21 
of the blood supply, 28 
of the lymphatics, 29 
of the nerve supply, 29 
of the venous supply, 28 
of the sacrum, 26 
of the sigmoid colon, 27 
Anemia as symptom of rectal dis- 
ease, 35 
Anesthesia, local, for operations 
on hemorrhoids, 176 
technic of the use of, 263-280 
Anesthetizing the sphincters, 
amount of distention nec- 
essary for, 212 
point of puncture for, 273 
Anguillula intestinalis, 316 

stercoralis, 316 
Animal parasites in feces, 308 
Ankylostoma diiodenale, 312 
Anorectal region, abscess of the, 

129-140 
Anoscope, fenestrated, author's, 54 
Kelly, 56 

with oblique opening, author's, 
54 
Anoscopy, 55, 56 

in diagnosis of hemorrhoids, 171 
instruments for, 55 
knee-shoulder position in, 56 
posture and method in, 57 
Antiseptics in treatment of ame- 
bic dysentery, 242 
Anus, anatomy of the, 17 

congenital defect or malforma- 
tion of, examination for, 
64 
eversion of, 46 

vaginal, 45 
imperforate, 62, 65 
quadrants of the, 271 



INDEX 



327 



Appendico-cecostomy for chronic 
amebic dysentery, 252 

Arteries of the rectum, 28 

Ascaris lumbricoicles, 310 

Atresia ani vaginalis, complete, 
63, 65 
incomplete, 64, 65 



B 

Bacillus coll communis, 218 
dysenterioc, 219 

Backache, sacral, as symptom of 
rectal disease, 34 

Bacteria of symbiosis, 226 

Balantidium coU, 224, 309 

Ball's operation for pruritus ani, 
111-115 
Krouse's modification of, 115 

Beck's bismuth paste, injection 
of, 55, 156 

Benzidin test for occult blood in 
feces, 306 

Beta-eucain for local anesthesia, 
264 

Bile in physiology of defecation, 70 
pigment in feces, clinical sig- 
nificance of, 303 

Bilirubin in feces, clinical sig- 
nificance of, 303 

Bismuth meal, radiograph of, 80, 
81 
paste, injection of fistulous 
tracts with, 55, 156 

Bivalve rectal speculum, 167 

Blackwash for pruritus ani, 107 

Bleeding as symptom of hemor- 
rhoids, 165 
of rectal disease, 31 

Blood in feces, clinical significance 
of, 305 
supply of the rectum, 28 

Bloodless operation for hemor- 
rhoids, author's, 180 

BothriocepTialus latus, 319 

Bougie, Wales, 86, 279, 289 



Bulbocavernosus muscle, anatomy 
of the, 18, 24 



Calomel for dysentery, 241 
Cancer, differential diagnosis of 
hemorrhoids from, 172 
of the rectum, 283 

protoscopic view of, 284 
with multiple fistulas, 285 
Carbolic acid for injection of 
hemorrhoids, 175 
for pruritus ani, 107 
Case reports of amebic dysentery, 
231, 232 
with pellagra, 234-237 
Cauterization, linear, for prolapse 
of the rectum, 259 
by actual cautery, 261 
by nitric acid, 260 
Cecum, ptosis of, 82, 83 
Cercomonas intestinalis in acute 

catarrhal dysentery, 218 
Cestode worms, 317 
Chemical examination of feces, 299 
Chloretone for dysentery, 242 
Cholera nostras, character of 

feces in, 320 
Citrine ointment for pruritus ani, 

107 
Clamp and cautery operation for 

hemorrhoids, 187 
Climate in etiology of dysentery, 

215 
Cocain for local anesthesia, 263 

hydrochlorate in dysentery, 242 
Coccyx, anatomy of the, 24, 26 

examination of the, 48 
Colitis, 214 

mucomembranous, character of 
feces in, 320 
Colon, atrophy of descending, 75 
hypertrophy of, 77, 78 
overdistention of, 76 
sigmoid, anatomy of the, 27 



328 



INDEX 



Coloptosis, 79 

Colostomy, 288 

Columbus operating-table, 38, 48 

Columns of Morgagni, anatomy of, 

22 
Concretions, removal of, from 

rectum or sigmoid, 291 
Congenital defects of anus or 
rectum, examination for, 
64 
Constipation, 66-90 

as symptom of rectal disease, 34 
definition of, 66, 67 
diagnosis of, 73 
proctoscopy in, 74 
radiography in, 74 
etiologic factors in, 70 
neglect as, 71 
use of vegetables as, 71 
use of water as, 71 
treatment of, 84 

author's method for, 86 
diet in, 84 
exercise in, 85 
inflation of rectum in, 86 
liquid albolene in, 89, 90 
massage in, 85 
mechanical dilatation in, 85 
nux vomica in, 89 
pancreatin, in, 89 
petrolatum in, 89, 90 
pneumatic dilator for, 86 
tamponing the rectum in, 85 
Coprology, 293 

Corrugator cutis ani muscle, 17 
Cryptitis, 198-200 

treatment of, 199 
Crypts of Morgagni, anatomy of, 
19 
tearing-down of, cause of anal 
fissure, 119 

D 

Defecation,, physiology of, 67 
DeVilbiss rectal speculum, 136 
spray tube, 203 



Diagnosis of abscess, intermural, 
135 
marginal, 133 
perineal, 131 
rectal, 138 
submucous, 135 
subtegumentary, 133 
tegumentary, 131 
of anal fissure, 120 

fistula, blind internal, 154 
simple complete, 143 
tuberculous, 158 
of constipation, 73 
of dysentery, acute catarrhal, 
219 
amebic, 237 
diphtheritic, 220 
sporadic bacillary, 219 
of fecal impaction, 97 
of hemorrhoids, 169 

differential, 171 
of hypertrophied rectal papillae, 

196 
of proctitis and sigmoiditis, 
acute, 202 
chronic atrophic, 211 
chronic hypertrophic, 208 
of prolapse of the rectum, 256 
of pruritus ani, 103 
of rectal polypus, 191 
Diarrhea as symptom of rectal dis- 
ease, 34 
Diet in constipation, 84 

in dysentery, 238 
Digital examination, 42 
finger cots for, 42, 43 
in diagnosis of hemorrhoids, 

171 
lubricants for, 42 
of coccyx, 48 
posicion for, 43 
correct, 44 
incorrect, 43 
lithotomy, 47, 48 
rectoabdominal, 45, 48 
vaginorectal, 46, 48 



INDEX 



329 



Dilatation, mechanical, for consti- 
pation, 85 
Dilator, pneumatic, for constipa- 
tion, 86 
Diphtheritic dysentery, 219 

enteritis, character of feces in, 
320 
Director, grooved, 148 
Discharge as symptom of rectal 

disease, 33 
Disturbances, general, as symptom 
of rectal disease, 35 
urinary, as symptom of rectal 
disease, 35 
Dochmius cluodenalis, 312 
Douglas' pouch, 26 
Dressing, rectal. 111 
Dysenteric ulceration on valves of 

Houston, 229 
Dysentery, 214-253 
acute catarrhal. 218 
diagnosis of, 219 
etiology of. 218 
pathology of, 218 
prognosis of. 219 
symptoms of, 218 
amebic, 220 

case reports of, 231 
character of feces in, 321 
chronic, 248 

appendico-cecostomy for, 
252 
complications of, 233 
diagnosis of, 237 
etiology of, 222 
pathology of, 226 
pellagra with, 234 
prognosis of, 237 
secondary, 248 
sequelae of, 233 
symptoms of, 230 
synonyms of, 221 
treatment of, 238 
antiseptics in, 242 
dietetic, 238 
irrigation of colon in, 247 



Dysentery, amebic — cont'd. 
laxatives, in, 241 
prophylactic, 238 
remedial, 240 
character of feces in, 321 
definition of, 214 
diphtheritic, 219 

complications of, 220 

definition of, 219 

diagnosis of, 220 

etiology of, 219 

pathology of, 220 

secondary, 221 
prognosis of, 221 
symptoms of, 221 

symptoms of, 220 
etiology of, 215 

climate in, 215 

drinking water in, 217 

foods in. 217 

poor hygiene in, 215 

race in, 215 

season in, 215 

sex in, 215 

topography and condition of 
soil in, 216 
general considerations of, 214 
geographical distribution of, 215 
history of, 214 
sporadic bacillary, 218 

diagnosis of, 219 

etiology of, 218 

pathology of, 218 

prognosis of, 219 

symptoms of, 218 
synonyms of, 214 

E 
Electric magnifying headlight, 39 
Elevations as symptom of rectal 

disease, 33 
Enemata for pruritus ani, 108 
Entamoeba histolytica, 222, 225, 

237 
Enteritis, diphtheritic, character 

of feces in, 320 
Erythema, treatment of, 106 



330 



INDEX 



Etiology of acute proctitis and sig- 
moiditis, 201 
of constipation, 70 
of dysentery, 215 
acute catarrhal, 218 
amebic, 220 
diphtheritic, 219 
sporadic bacillary, 218 
of prolapse of the rectum, 255 
Eversion of anus, 46 

vaginal, 45 
Examination of feces, chemical, 
299 
clinical, 296 
for amebse, 225 
microscopic, 298 
of hypertrophied rectal papillae, 

196 
of marginal abscess, 133 
of patient, 36-65 
anoscopy in, 55 
digital, 42 

electric headlight for, 38 
eversion of anus in, 46 
for congenital defects or mal- 
formation, 64 
internal inspection in, 50 
knee-shoulder position for, 51 
lithotomy position for, 47 
location of rooms for, 36 
proctoscopy in, 56-61 
record cards for, 40, 41 
rectoabdominal, 45 
rooms and furniture in, 36 
sigmoidoscopy in, 62-64 
Sims' position for, 41 
squatting position for, 49, 52 
vaginorectal, 46 
Exercise in constipation, 85 
Excision of anal fissure, 126 
fistula, 150 
ulcer, 128 
of hemorrhoids, 178 
submucous, 186 
External sphincter muscle, anat- 
omy of, 18, 19, 24 



F 

Fecal impaction, 96-99 
cause of, 96 
diagnosis of, 97 
symptoms of, 96 
treatment of, 98 

author's massage bag in, 99 
liquid albolene in, 98 
peroxid of hydrogen in, 98 
Feces, amount of, 294 

and their clinical examination, 

293-321 
animal parasites in, 308 
character of, in acute intestinal 
catarrh, 320 
in amebic dysentery, 321 
in chronic inflammation of in- 
testines, 320 
in cholera nostras, 320 
in diphtheritic enteritis, 320 
in dysentery, 321 
in mucomembranous colitis, 
320 
color of, 295 

consistency and form of, 294 
duration of passage of, 293 
examination of, chemical, 299 
estimation of lost albumin 

residue in, 301 
fermentation test in, 301 
reaction in, 299 
sublimate test in, 300 
clinical, 296 

test-diet in, 296 
for amebse, 225 
microscopic, 298 
signiflcance of tests in, 302 
bile pigment, 303 
bilirubin, 303 
blood, 305 
excess of connective tissue, 

304 
excess of undigested muscle- 
fiber, 304 
fat, 304 
gallstones, 307 



INDEX 



331 



Feces, examination of — conVd. 
hyaline cells, 303 
mucus, 302 

pathologic albumin fermen- 
tation, 304 
pathologic carbohydrate fer- 
mentation, 304 
pus, 305 

remnants of meat, 304 
semidigested cells, 303 
general characteristics of, 293 
macroscopic elements in, 295 
microscopic elements in, 296 
number of stools of, 293 
odor of, 294 
Fermentation apparatus. Steele's, 
300, 301 
test for chemical examination 
of feces, 301 
Finger cots for digital examina- 
tion, 42, 43 
Fissure, anal, 117-128 

differential diagnosis of hem- 
orrhoids from, 171 
local anesthesia for, 276 
Fistula, anal, 141-158, 290 
blind external, 153 

internal, 154 
communicating with other or- 
gans, 292 
complete, complicated, 146 
direct, 144 
multiple. 147 
simple, 142 
excision of, 150 
in tuberculous patient, 157 
incision of. 148 
ligature operations for. 151 
local anesthesia for, 276 
mucocutaneous, 156 
submucous tract, 156 
Folds of Houston, anatomy of, 22 
Foods in etiology of dysentery, 217 
Forceps, author's hemorrnoidal, 
181 
long alligator, 55 



Forceps — conVd. 

sharp-toothed or pronged, 125 
T-, 112 

Foreign body, history of swallow- 
ing, calls for rectal exami- 
nation, 35 
local anesthesia in removal of, 
278 

Formalin solutions for dysentery, 
245 

Formalin-boric solutions for dys- 
entery, 244 

Fossa, ischiorectal, anatomy of, 26 

Furniture for examination of pa- 
tient. 36 



Gallstones in feces, clinical sig- 
nificance of, 307 

Gluteus maximus muscle, anatomy 
of the, 24 

H 
Hanes position in sigmoidoscopy, 

61, 64 
Helminthiasis, 309 
Hemorrhage as symptom of hem- 
orrhoids, 165 
of rectal disease, 31 
diseases causing, 31 
Hemorrhoidal forceps, author's, 

181 
Hemorrhoids, 159-190, 290 

acute thrombotic, local anesthe- 
sia for, 274 
removal of, 188 
causes of. loo 
diagnosis of, 169 
anoscopy in, 171 
differential, 171 
from cancer, 172 
from enlarged papillae, 173 
from fissure, 171 
from polypi, 173 
from prolapse,173 
from protrusions, 172 
from ulcer, 172 



332 



:ndex 



Hemorrhoids, diagnosis of — conVcl. 
from venereal warts, 173 
digital examination, 170 
proctoscopy in, 171 
sigmoidoscopy in, 171 
external, 162 
cutaneous, 164 
distention of, with sterile 

water, 189 
integumentary, 162 

removal of, 188 
local anesthesia for, 274 
thrombotic, 162, 163 
varicose, 163 
internal, 161 

anesthetized, 183 
capillary, 163 
granular, 163 
prolapsing, 165-168 
varicose, 163 
interno-external, 160, 161 

injected for operation, 177 
prolapsing, distention necessary 

for anesthesia in, 178 
symptoms of, 165 
bleeding, 165 
pain, 167 
prolapse, 168 
treatment of, lv4 
adrenalin in, 174 
injection, 175 

carbolic acid for, 175 
operative, 176 
author's bloodless, 180, 184 
clamp and cautery, 187 
excision in, 178 
other methods of, 187 
submucous excision in, 186 
Whitehead, 187 
palliative, 174 
varieties of, 161 
with pruritus ani, 104 
Hepatic abscess complicating ame- 
bic dysentery, 230 
Herpes, treatment of, 106 
Hilton, white line of, 20 



Holland's modification of Weber's 
test for occult blood in 
feces, 306 
Hookworms, 312, 313 
Hypertrophy of the anal papillae, 
193-198 
diagnosis of, 196 
differentiated from polypus, 

196 
examination of, 196 
local anesthesia for, 277 
proctoscopic view of, 197 
symptoms of, 196 
of the rectal valves, local anes- 
thesia for, 277 

I 
Ichthyol for acute proctitis, 206 
for anal fissure, 121 
for chronic proctitis, 209 
Idiopathic pruritus ani, 101 
Iliococcygeus muscle, anatomy of, 

23 
Impaction, fecal, 96-99 
Imperforate anus, 62-65 
Incision of anal fissure, 124 

fistula, 148 
Inflammation of intestines, chronic, 

character of feces in, 320 
Inflation of rectum in constipa- 
tion, 86 
Injection of anal fissure, 123 
of bismuth paste, 55, 156 
of local anesthetic, for operating 
on hermorrhoids, 177, 178 
point of puncture for, 270 
treatment of hemorrhoids, 175 
Instrument and dressing sterilizer, 
37 
sterilizer, 37 
Intermural abscess, 134 
Internal sphincter muscle, anat- 
omy of, 18, 20, 23, 24 
Interno-external hemorrhoids, 160, 

161 
Intestinal catarrh, acute, character 
of feces in, 320 



INDEX 



333. 



Intestinal — conVd. 

ulcer, edge of, 228 
lodin for dysentery, 246 
Ipecaciiahana for dysentery, 243 
Irrigations of colon for acute ca- 
tarrhal proctitis, 203 
for amebic dysentery, 247 
with Jelks' colon tube, 206 
Ischiorectal abscess, 51, 137 
fossa, anatomy of the, 26 
Itching as symptom of rectal dis- 
ease, 32 
Itch-mite as cause of pruritus ani, 
101 



Jelks' recurrent-flow soft-rubber 
colon tube, 206, 245 

K 

Kelly anoscope, 56 

sigmoidoscope, 60, 63 
Kerosene oil for dysentery, 245 
Klunge's aloin test for occult blood 

in feces, 306 
Knee-elbow position, 53 
Knee-shoulder position for diagno- 
sis of constipation, 74 
for internal inspection, 51 
for proctoscopic examination, 

53, 58 
for spraying rectum, 204, 205 
in anoscopy, 56 
Krameria for chronic proctitis, 209 

for spraying rectum, 205 
Krouse's modification of Ball's op- 
eration for pruritus ani, 
115 



Laxatives in treatment of amebic 

dysentery, 241 
Levator ani muscle, anatomy of, 

23, 24 
Ligaments, anatomy of the, 25 
anococcygeal, 25 
lateral, 25 



Ligature carrier, author's blunt- 
pointed, 182 
author's rubber, 92 
operation for anal fistula, 151 
Limitations of local anesthesia and 

office treatment, 281 
Linea dentata, 17, 19, 195 
Lithotomy position for digital ex- 
amination, 47, 48 
for surgery of pruritus ani, 
109 
Liver in physiology of defecation, 

70 
Local anesthesia, amount of dilata- 
tion of sphincter under, 
275 
anesthetic agents for, 263 
beta-eucain for, 264 
cocain for, 263 
contraindications to, 282 
anal fistula, 290 
cancer of the rectum, 283 
hemorrhoids, 290 
fistulae communicating with 

other organs, 292 
prolapse of the rectum, 291 
rectal abscesses, 289 
removal of concretions, 291 
stricture of the rectum, 288 
ulceration of the bowel, 288 
for anal fissure, 276 

fistula, 276 
for hemorrhoids, 176 
acute thrombotic, 275 
external, 274 
for hypertrophied anal papil- 
la, 277 
rectal valves, 277 
for perianal abscess, 276 
for removal of benign perianal 
growths, 278 
of foreign bodies, 278 
in posterior internal procto- 
tomy, 279 
instruments for, 268 
limitations of, 281 



334 



INDEX 



Local anesthesia — cont'd. 
needle for, 268 
quinin and urea hydrochlorid 

for, 264-266 
sterile water for, 267 
technic of, 263-280 
general, 269 
in special cases, 274 
Lubricants for digital examination, 

42 
Lymphatics of the rectum, 29 

M 
Malformation of the anus or rec- 
tum, examination for, 64 
Marginal abscess, 131 
Martin proctoscope, author's modi- 
fication of, 58 
Massage bag, author's dilating, 86, 
87, 89 
in constipation, 85 
rectal, author's method of, 88 
Medio cannulata. 317 
Megacolon, 77, 78 

Menstruation, crampy, painful, and 
scanty, as symptom of rectal 
disease, 35 
Mesosigmoid, anatomy of the, 27 
Microscopic elements in feces, 296 

examination of feces, 298 
Morestin, lesser sphincterian nerve 

of, 29 
Morgagni, columns of, anatomy of, 
22 
crypts of, anatomy of, 19 
Mucomembranous colitis, charac- 
ter of feces in, 320 
Mucus as symptom of rectal dis- 
ease, 33 
clinical significance of, in feces, 
302 
Muscle, bulbocavernosus, 18, 24 
corrugator cutis ani, 17 
gluteus maximus, 24 
iliococcygeus, 23 
levator ani, 23 
pubococcygeus, 24 



Muscle — cont'd. 

puborectalis, 18, 25 
rectourethralis, 18, 23 
sphincter recti, 25 

external, 18, 19, 24 

internal, 18, 20, 23, 24 
transversus perenei, 24 

N 

Nematodes, 310 

Nerve supply of the rectum, 29 

Nerves of the rectum, 29 

Neuralgia of the rectum caused by 
hypertrophied papillae, 198 

Nitrate of silver for anal fissure, 
121 
for pruritus ani, 108 

Nitric acid cauterization for pro- 
lapse of the rectum, 260 

Nux vomica in treatment of consti- 
pation, 89 

O 

Obstipation, 90-95 

causes of, 67 

definition of, 67 

rectal valves in, 91 
Odor of discharge as symptom of 
rectal disease, 34 

of feces, 294 
Ointment for anal fissure, 122 

for dysentery, 244 

for pruritus ani, 106, 107 
Operating-room, 36 

-table, Columbus, 38, 48 
Opium for dysentery, 241 
Oxyuris vermicularis, 311, 312 
as cause of pruritus ani, 101 



Pain as symptom of hemorrhoids, 
167 
of rectal disease, 30, 35 
Palpation of rectum, 50 

rectoabdominal, 50 
Pancreatin in treatment of consti- 
pation, 89 



IXDEX 



335 



Papillae, anal, anatomy of, 19 

hypertrophy of, 193-198 

differential diagnosis of, 
from hemorrhoids, 173 
Paramcecium coli. 218, 224, 309 
Parasites, animal, 308 

Amceha coli. 308 

AnguiUula intestinalis. 316 
stercoralis, 316 

Ankylostoma diiodenale, 312 

Ascaris himhricoides, 310 

BaJantidiiim coli, 308 

Botfiriocephalus Jatus, 319 

cestode worms, 317 

Dochmius duodenalis, 312 

hookworm. 312, 313 

Medio canniilata. 317 

nematodes, 310 

Oxyuris vermicularis, 312 

pinworm, 312 

protozoa, 308 

round worms, 310 

seatworm. 312 

Strongylus duodenalis, 312 

Tcenia nana. 319 
saginata. 317, 318 
solium, 317 

tapeworms, 317-319 

threadworm, 312 

Trichina spiralis. 316 

Trichina^. 315 

Trichocephalus dispar. 314, 315 

Uncinaria americana. 313 
duodenalis, 312, 313 

whip worm. 315 

worms, 309 
Pathology of dysentery, acute ca- 
tarrhal. 218 

amebic, 226 

diphtheritic, 220 

sporadic bacillary, 218 
Patient, examination of the, 36-65 
Pediculus puhis, treatment of, 106 
Pellagra with amebic dysentery, 
234 



Perianal abscess, local anesthesia 

for, 276 
Perineal abscess, 130 
Peristalsis, intestinal, 68 
Pero'xid of hydrogen in fecal im- 
paction, 98 
injection of, for determining 
internal opening of fistula. 
55 
Petrolatum in treatment of consti- 
pation, 90 
Physiology* of defecation. 67 
bile in, 70 
chemical reaction of stomach 

contents in, 68 
creation of gases in, 68 
liver in, 70 
movements of intestines in, 68 

of respiration in, 69 
peristaltic action in. 67 
stimulation by particles of 
food in, 68 
Pinworms. 312 
Polypus rectal. 191, 192 

differentiated from hemor- 
rhoids, 173 
from hypertrophied papillae. 
196 
Position assumed by patients, in 
anorectal disease, 132, 133 
exaggerated lithotomy, in sig- 
moidoscopy, 62 
inverted or Hanes, in sigmoido- 

scopj', 61. 64 
knee-elbow, 53 

knee-shoulder, for anoscopy, 56 
for internal inspection, 51 
for proctoscopic examination. 

53, 58 
for spraying rectum. 204 
lateral, for digital examination, 
43. 44 
for surgery of pruritus ani. 
109 
left lateral, for external inspec- 
tion, 41 



336 



INDEX 



Position — confd. 

lithotomy, for digital examina- 
tion, 47, 48 
for surgery of pruritus ani, 109 
of patient for introduction of co- 
lon tube, 249 
Sims', for digital examination, 
43, 44 
for dilating rectum, 87 
for external inspection, 41 
Pouch, Douglas', 26 

rectovesical, 26 
Probe, silver, 55 
Proctitis and sigmoiditis, 201-213 
acute, 201 

catarrhal, 203 
diagnosis of, 202 
etiology of, 201 
symptoms of, 202 
treatment of, 202 
chronic, 207 
atrophic, 210 

symptoms of, 211 
treatment of, 212 
hypertrophic, 207 
diagnosis of, 208 
symptoms of, 208 
treatment of, 208 
Proctoscope, author's four-inch op- 
erating, 92 
author's modification of Martin, 
58 
Proctoscopic view of cancer of the 
rectum, 284 
of submucous abscess, 135 
Proctoscopy, 56-61 

in diagnosis of hemorrhoids, 171 
technic of, 58 
without instruments, 57 
Proctotomy, posterior internal, for 

annular stricture, 279 
Prolapse as symptom of hemor- 
rhoids, 168 
differential diagnosis of hemor- 
rhoids from, 173 
of the rectum, 291 
in children, 254-262 



Prolapse of the rectum — cont'd. 
cauterization of, 259 
concealed, 254, 256, 258 
diagnosis of, 256 
etiology of, 255 
symptoms of, 256 
treatment of, 257 
Protozoa, 308 

Protrusions as symptom of rectal 
disease, 33 
differential diagnosis of hemor- 
rhoids from, 172 
Pruritus ani, 100-116 
after-treatment of, 115 
caused by hypertrophied papillae, 

198 
causes of, 100 
characteristic cracking of, 103 

itching of, 105 
diagnosis of, 103 
idiopathic, 101 
treatment of, 105 

author's operation in, 112 
Ball's operation in, 111 

Krouse's modification of, 115 
blackwash in, 107 
carbolic acid in, 107 
dusting powder in, 106 
enemata in, 108 
lotions in, 107 
mechanical vibrator in, 108 
nitrate of silver in, 108 
ointment in, 106, 107 
citrine, 107 
scarlet-red, 108 
prescriptions for, 107 
removal of kite-shaped flap of 

skin in, 110 
surgical measures in, 109 
with hemorrhoids, 104 
Ptosis of cecum, 82, 83 
Pubococcygeus muscle, anatomy of, 

24 
Puborectalis muscle, anatomy of, 

18, 25 
Pus in feces, clinical significance 
of, 305 



inde;x 



337 



Q 

Quadrants of the anus, 271 
Quinin and urea hydrocMorid for 
local anesthesia 264-266 

R 

Race in etiology of dysentery, 215 
Radiograph of bismuth meal, 80, 

81 
Radiography in diagnosis of con- 
stipation, 74 
Record cards, 40, 41 
Rectal abscesses, 289 
dressing. 111 
massage, author's method of, 87, 

88 
polypus, 191, 192 
diagnosis of, 191 
fibroid, 181 
granular, 191 
symptoms of, 191 
treatment of, 192 
retractor, modified from Sims' 

speculum, 182 
speculum, bivalve, 169 

DeVilbiss, 136 
spray tube, author's, 204 
valves, 91 

anatomy of the, 22, 91 
valvotomy, author's operation 
for, 93 
Rectoabdominal examination, 45, 
48, 49 
palpation, 50 
Rectourethralis muscle, anatomy of 

the, 18, 23 
Rectovesical pouch, 26 
Rectum, anatomy of the, 18, 20, 21 
arteries of the, 28 
blood supply of the, 28 
cancer of the, 283 

proctoscopic view of, 283 
congenital defect or malforma- 
tion of, examination for, 
64 



Rectum — cont'd. 

inflation of the, in constipation, 

86 
lymphatics of the, 29 
nerve supply of the, 29 
nerves of the, 29 
neuralgia of the, caused by hy- 

pertrophied papillae, 198 
palpation of the, 50 
prolapse of the, 291 

in children, 254-262 
relations of the, 26 
stricture of the, 288 
symptoms which should call at- 
tention to the, 30-35 
tamponing the, in constipation, 

85 
ulcer of the, 210 
veins of the, 28 
venous supply of the, 28 
Restlessness in children as symp- 
tom of rectal disease, 35 
Retractor, rectal, 182 
Ringv^-orm as cause of pruritus ani, 
101 
treatment of, 106 
Rooms for examination of the pa- 
tient, 36 
Round worms, 310 
Sacral backache as symptom of 

rectal disease, 34 
Sacrum, anatomy of the, 26 
Scabies, treatment of, 106 
Scarlet-red ointment for anal fis- 
sure, 122, 125 
for pruritus ani, 108 
Scissors, author's angular rectal, 
92 
curved on the flat, sharp-pointed, 
112 
Season in etiology of dysentery, 

215 
Seatworms, 312 
Sentinel pile, 119 

with anal fissure, 117 
Sex in etiology of dysentery, 215 



338 



INDKX 



Sigmoid colon, anatomy of the, 27 
Sigmoiditis, 201-213 

acute, 201 

chronic atrophic, 210 
hypertrophic, 207 
Sigmoidoscope, Kelly, 60, 63 

with author's tilting obturator, 

60, 63 
Sigmoidoscopy, 62-64 

exaggerated lithotomy position 

in, 62 
in diagnosis of hemorrhoids, 171 
inverted or Hanes position in, 

61, 64 

Sims' position for digital exami- 
nation, 43, 44 
for dilating rectum, 87 
for external inspection, 41 
for internal inspection of anal 
canal, 55 
Soil in etiology of dysentery, 216 
Spasm as symptom of rectal dis- 
ease, 31 
Speculuni, bivalve rectal, 169 

DeVilbiss rectal, 136 
Sphincter recti muscle, anatomy of 
the, 25 
tight contracted, 197 
Spray tube, author's rectal, 204 

DeVilbiss, 203 
Squatting position for diagnosis, 

49, 52 
Staphylococcus cause of tegumen- 

tary abscess, 131 
Sterilizer, instrument and dress- 
ing, 37 
Stomach contents, chemical reac- 
tion of, 68 
Stools, altered, as symptom of rec- 
tal disease, 34 
Streptococcus foBcalis cause of pru- 
ritus ani, 103, 109 
Stricture of the rectum, 288 

posterior internal proctotomy 
for, 279 
Strongylus cUiodenalis, 312 



Sublimate test in chemical exami- 
nation of feces, 300 
Submucous abscess, 131 
excision of hemorrhoids, 186 
tract, 156 
Subtegumentary abscess, 131 
Suppository for anal fistula, 122 
for dysentery, 243, 244 
for hemorrhoids, 183 
Surgical measures for pruritus ani, 
109 
treatment of anal fissure, 123 
Symbiosis, bacteria of, 226 
Symptoms which should call at- 
tention to the rectum, 30- 
35 
Syringe, all-glass hypodermic, 268 
all-metal, 269 
all-rubber bulb, 50, 52 



T-forceps, 112 
Twnia nana, 319 
saginata, 317, 318 
solium, 317 
Tamponing the rectum in consti- 
pation, 85 
Tapeworms, 317-319 
Tegumentary abscess, 130 
Tenderness as symptom of rectal 

disease, 31 
Test, fermentation, in examination 
of feces, 301 
for estimation of lost albumin 

residue in feces, 301 
for occult blood in feces, benzi- 
din, 306 
Holland's, 306 
Klunge's aloin, 306 
Weber's, 306 
sublimate, in examination of fe- 
ces, 299 
Test-diet in clinical examination of 

feces, 296 
Threadworms, 312 

as cause of pruritus ani, 101 



INDi:X 



339 



Threadworms — cont'd. 

treatment for, 106 
Thymol for dysentery, 246 
Toilet rooms, provision for, 72, 73 
Tract, submucous, 156 
Treatment of abscess, intermural, 
136 
marginal, 133 
perineal, 131 
rectal, 139 
submucous, 136 
subtegumentary, 133 
tegumentary, 131 
of amebic dysentery, 238 
of anal fissure, 121 

fistula, blind external, 154 
blind internal, 155 
simple complete, 148 
tuberculous, 158 
of constipation, 84 
of cryptitis, 199 
of erythema, 106 
of fecal impaction, 98 
of hemorrhoids, 174 
of herpes, 106 
of Pecliciilus pubis, 106 
of proctitis and sigmoiditis, 
acute, 202 
chronic atrophic, 212 
hypertrophic, 208 
of prolapse of the rectum, 257 
of pruritus ani, 105 
of rectal polypi, 192 
of ringworm, 106 
of scabies, 106 
of threadworm, 106 
Trichina, 315 
spiralis, 316 
Trichoceplialus dispar, 314, 315 
TricJiomonas intestinalis, 218 
Trichophyton as cause of pruritus 
ani, 101 
treatment of, 106 
Tuberculous anal fistula, 157 



U 
Ulcer, anal, 128 

differential diagnosis of hemor- 
rhoids from, 172 
intestinal edge of, 228 
of the rectum, 210 
Ulceration of the bowel, 288 
TJncinaria americana, 312, 313 

duodenalis, 312, 313 
Urinary disturbances as symptom 
of rectal disease, 35 



Vaginorectal examination, 46, 48 
Valves of Houston, dysenteric ul- 
ceration on, 229 
rectal, 91 

anatomy of the, 22, 91 
Valvotomy, 91 
needle, 92 

rectal, author's operation for, 93 
Veins of the rectum, 28 
Venous supply of the rectum, 28 
Vibrator, mechanical, for constipa- 
tion, 85 
for dilatation of sphincter, 269, 

274 
for pruritus ani, 108 

W 

Wales bougie, 86, 279, 289 

Warts, differential diagnosis of 
hemorrhoids from, 174 

Water, drinking, in etiology of dys- 
entery, 217 

Weber test for occult blood in 
feces, 306 

Whip worm, 315 

White line of Hilton, 20 

Whitehead operation for hemor- 
rhoids, 187 

Worms in feces, 309 
cestode, 317 
nematode. 310 



FEB 8 1913 



